Leonard P. Krajewski

Surgical management of infected abdominal aortic grafts: Review of a 25-year experience*

Eighty-four patients with infected abdominal aortic grafts managed from 1961 through February 1985 were reviewed. Thirty-three patients had associated aortoenteric fistula formation. Twenty-eight infections (33%) and 13 aortoenteric fistulas (39%) originated at The Cleveland Clinic, yielding an incidence of aortic graft infection of 0.77% (28 of 3652 grafts) and aortoenteric fistula formation of 0.36% (13 of 3652 grafts) at this center. Staphylococcus organisms alone or in combination with other organisms were isolated from 34% of the series. Management consisted of graft removal and extra-anatomic bypass in 54 patients (64%), graft removal alone in 14 (17%) patients, partial graft removal and extra-anatomic bypass in seven (8%) patients, and miscellaneous operations in nine (11%) patients. Twenty-three patients (27%) required major amputations, nine of which were bilateral. Life-table analysis yielded 30-day and 1-year survival rates of 72% and 42%, respectively. Thirty-day survival of the aortoenteric fistula subset (49%) was less than that (86%) of the nonaortoenteric fistula subset (p = 0.003). One-year survival of patients treated since 1980 (54%) was superior to that of patients treated before 1980 (31%, p = 0.035). No difference in operative or 1-year survival was demonstrated between the group treated with extra-anatomic bypass and subsequent graft removal and another in which both procedures were performed simultaneously, although the staged group experienced substantially fewer (p = 0.04) amputations (7%) than the combined group (41%).

Thoracoabdominal aneurysm repair: a representative experience.

Between May 1966 and June 1991, 129 patients underwent surgical repair of thoracoabdominal aneurysms, with an overall 30-day mortality rate of 35%. In 75 operations (58%) performed electively, 11 deaths (15%) occurred, and in 54 cases (42%) of either symptomatic or ruptured aneurysms 34 deaths (63%; p less than 0.001) occurred. No one survived among six patients with preoperative hypotension (less than 90 mm Hg) or cardiac arrest. In 16 patients (12%) the etiology of aneurysms was a result of chronic aortic dissection, and the mortality rate in this subgroup was 44%. In the remaining 113 patients (88%) where the etiology was atherosclerosis, 38 deaths occurred (34%; p = 0.433). Spinal cord ischemia occurred in 25 cases (21%) among 116 patients who survived operation. Partial ischemia occurred in six cases (25%), and complete paraplegia occurred in the remainder. Complete and partial paraplegia occurred in 16 of 42 cases (38%) when all of the thoracic aorta was replaced (Crawford groups I, II) and in 9 of 74 cases (12%) when only the abdominal or lower thoracic aorta was replaced (Crawford groups III, IV; p = 0.016). Other complications included myocardial infarction (14 cases, 11%), respiratory failure (46 cases, 36%), and renal failure (33 cases, 27%). The major prospect for improved early survival of patients with thoracoabdominal aneurysms seems to be early detection and elective repair before the occurrence of symptoms.

Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: The Cleveland Clinic experience from 1989 to 1995

PURPOSE Several randomized trials now have established guidelines regarding patient selection for carotid endarterectomy (CEA) that have been widely accepted but have little relevance unless they are considered in the context of perioperative risk. The purpose of this study was to demonstrate the feasibility of early outcome assessment using a computerized database. METHODS Since 1989 demographic information and in-hospital results for all surgical procedures performed by the members of our department have been entered into a prospective registry. For the purpose of this report, we have analyzed the stroke and mortality rates for 2228 consecutive CEAs (2046 patients), including 1924 that were performed as isolated operations and 304 that were combined with simultaneous coronary artery bypass grafting (CABG). This series incidentally contains a total of 153 reoperations for recurrent carotid stenosis. RESULTS The respective stroke and mortality rates were 0.5% and 1.8% for all isolated CEAs, 4.3% and 5.3% for all CEA-CABG procedures, and 4.6% and 2.0% for carotid reoperations. According to a multivariable statistical model, the composite stroke and mortality rate for isolated CEA was significantly influenced by female gender (p = 0.050), by the urgency of intervention (p = 0.026), and by carotid reoperations (p = 0.024). Gender (p = 0.030) and urgency (p = 0.040) also were associated with differences in the stroke rate alone; furthermore, the incidence of perioperative stroke was higher in conjunction with synthetic patching (odds ratio, 2.6; 95% confidence interval, 1.2 to 5.3) and was marginally higher with primary arteriotomy closure (odds ratio, 2.7; 95% confidence interval, 0.8 to 9.5) compared with vein patch angioplasty (1.3%). The method used to repair the arteriotomy was the only independent factor that qualified for the multivariable composite stroke and mortality models that were applied to the combined CEA-CABG procedures, but too few patients in this cohort had synthetic patches or primary closure to validate the perceived superiority of vein patching. CONCLUSIONS Prospective outcome assessment is essential to reconcile the indications for CEA with its actual results, and it may lead incidentally to important observations concerning patient care.

A prospective study of vein patch angioplasty during carotid endarterectomy. Three-year results for 801 patients and 917 operations.

From 1983 through 1985, 801 consecutive patients (mean age: 66 years) underwent 917 primary carotid endarterectomies at the Cleveland Clinic. Conventional arteriotomy closure was performed during 483 operations, while patch angioplasty using a distal segment of saphenous vein was employed in 434. Preoperative risk factors, surgical management, and antiplatelet therapy were equivalent in the vein patch (VP) and nonpatch (NP) groups. Early results were evaluated by intravenous angiography (DSA) in 715 patients (89%), and 332 reconstructions (36%) have been reassessed by objective imaging during a mean follow-up interval of 21 months. Ischemic strokes occurred after 18 (1.9%) of the 917 procedures (0.7% VP, 3.1% NP; p = 0.0084), and symptomatic (N = 9) or unsuspected (N = 8) thrombosis of the internal carotid artery was confirmed by neck exploration or routine DSA after 1.9% of all operations (0.5% VP, 3.1% NP; p = 0.0027). Only ten patients (1.2%) have required reoperations for severe recurrent lesions, but the cumulative 3-year incidence of new defects (greater than or equal to 30% stenosis) documented by objective studies in the VP and NP groups was 9% and 31%, respectively (p = 0.0066). These results strongly suggest that VP angioplasty enhances the safety and durability of carotid endarterectomy.

Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: Early results and late outcomes

PURPOSE The purpose of this study was to determine the safety and efficacy of the elective surgical treatment of symptomatic chronic mesenteric occlusive disease (SCMOD) and to identify the factors that influence the results of this procedure. METHODS From 1977 to 1997, 85 patients (mean age, 62 years) underwent elective surgical treatment of SCMOD. The presenting symptoms were abdominal pain in 78 patients (92%) and weight loss in 74 patients (87%). The surgical procedures included retrograde bypass grafting in 34 patients (40%), antegrade bypass grafting in 24 patients (28%), transaortic endarterectomy in 19 patients (22%), local arterial endarterectomy with patch angioplasty in six patients (7%), thrombectomy alone in one patient (1%), and superior mesenteric artery reimplantation in one patient (1%). Thirty-five patients (41%) underwent concomitant aortic replacement. All the involved mesenteric vessels were revascularized in 21 patients (25%), whereas revascularization was incomplete for the remaining 64 patients (75%). Late information was available for all 85 patients at a mean interval of 4.8 years. RESULTS There were seven early (<35 days) postoperative deaths (8%). The cumulative 5-year survival rate was 64% (95% confidence interval [CI], 53% to 75%), and the 3-year symptom-free survival rate was 81% (95% CI, 72% to 90%). Serious complications occurred in 28 patients (33%). The results of univariate analysis identified advancing age at operation (P <.001), cardiac disease (P =.03), hypertension (P =.03), and additional occlusive disease (P =.05) as variables associated with mortality. Concomitant aortic replacement (P =.037), renal disease (P =.011), advancing age ( P =.035), and complete revascularization ( P =.032) were associated with postoperative morbidity including mortality. Late recurrent mesenteric occlusive disease was seen in 21 patients (16 symptomatic and five asymptomatic). Nine patients (43%) died, and 8 patients (38%) required subsequent surgical or endovascular procedures to treat their recurrent lesions. The 3-year survival rate from recurrent mesenteric occlusive disease was 76% (95% CI, 66% to 86%). CONCLUSION We conclude that the elective surgical treatment of SCMOD may be performed with reasonable early and late mortality rates and that most of the patients remain free from recurrent symptoms of mesenteric ischemia. Advancing age, cardiac disease, hypertension, and additional occlusive disease significantly influenced the overall mortality rates, and concomitant aortic replacement, renal disease, and complete revascularization were significantly associated with postoperative morbidity rates. Surveillance and appropriate correction of recurrent disease appear to be necessary for optimal long-term results.

Blunt carotid artery trauma: report of two cases and review of the literature.

Blunt carotid artery trauma is uncommon but has been associated with severe, permanent neurologic deficits in 42% and mortality in 30% of 96 patients previously reported in the English literature. Since neurologic symptoms characteristically develop only after a latent interval and since physical evidence of significant cervical trauma often is absent, diagnosis of nonpenetrating carotid injuries with the use of arteriography usually is delayed until the appearance of obvious, frequently irreversible neurologic complications. Carotid injuries should be suspected in patients who develop monoplegia or hemiplegia following blunt craniocervical trauma, particularly if computerized tomography excludes the presence of intracranial hemorrhage. The cumulative results of a collected series of 96 patients suggest that early surgical correction of blunt carotid injuries is appropriate for patients with transient episodes of cerebral ischemia, strokes in evolution, or mild completed neurologic deficits.

Combined staged procedures for the treatment of thoracoabdominal aneurysms.

Purpose: To examine the efficacy of a staged approach for the treatment of thoracoabdominal aneurysms, with open visceral revascularization followed by aortic endografting, in selected patients not considered candidates for conventional surgical repair. Methods: A retrospective review was conducted of 13 consecutive patients (8 women; mean age 64 years, range 33–77) who underwent visceral bypass followed by endovascular thoracoabdominal stent-graft implantation since 1999. Three patients presented with symptomatic aneurysms and 2 with rupture. Two patients had connective tissue disorders. All patients were deemed unfit for conventional thoracoabdominal repair due to comorbid conditions. The procedures were tailored to the pathology and specific patient anatomical situation: 5 aortic dissections with aneurysmal degeneration and 8 aneurysms (5 Crawford type II, 2 type III, and 1 type IV). Results: The patients underwent retrograde visceral bypass (11 iliovisceral and 2 infrarenal aortic to visceral artery) followed by endovascular aortic relining with Zenith TX2 devices (n=7), homemade endografts (n=5), or a Talent thoracic endograft (n=1). Six patients required either a proximal or distal direct aortic repair (2 infrarenal reconstructions, 3 arch elephant trunk grafts, and 1 ascending aortic repair), while 3 patients also underwent left carotid-subclavian bypass grafting. Two patients developed paraplegia (1 following a ruptured aneurysm), and 2 patients had transient paraparetic events. Two patients had acute renal failure requiring short-term dialysis. Three patients died within 30 days; 2 late aneurysm-related deaths were noted. Three patients developed endoleaks during follow-up. Mean lengths of stay were 13 days (7–30) for the visceral bypass and 12 (3–25) for the endovascular stent-graft. In addition, remaining procedures in 8 patients required a mean of 7 days (0–14) in hospital. Conclusion: Staged endovascular and open procedures are feasible for thoracoabdominal aneurysms in patients at prohibitive risk for open thoracoabdominal reconstruction. However, this approach still carries a significant risk of perioperative mortality and morbidity. The potential for less invasive alternatives should be investigated.

Thrombolysis of peripheral arterial bypass grafts: Surgical thrombectomy compared with thrombolysis ☆ ☆☆: A preliminary report

Twenty-two patients were selected from a group of 33 patients who underwent recombinant human tissue-type plasminogen activator (rt-PA) thrombolysis for thrombosed infrainguinal bypass grafts of the lower extremity and were compared with 38 matched patients who had undergone surgical thrombectomy during the same period. The proportion of persons with diabetes mellitus, smokers, and types of bypass grafts was similar in both groups. More patients in the rt-PA-treated group had hypertension (p = 0.01). To evaluate the different lengths of follow-up, Kaplan-Meier survival analysis was used with a log-rank test to compare the proportion of persons with patent grafts in the two treatment groups. At 30 days, 86% of the rt-PA-treated grafts were still patent compared with 42% of the surgically treated grafts (p = 0.001). When risk factors on the Kaplan-Meier curves were compared, there was no statistical difference with regard to graft patency among the groups. According to simultaneous Cox regression analysis, no risk factor was significantly associated with graft patency. When amputation was evaluated between treatment groups simultaneously with other risk factors in a logistic regression analysis, smoking and age of the graft were marginally significant (p = 0.07), whereas all other factors were clearly not significant. In 91% of the rt-PA-treated patients, a secondary surgical procedure was required to maintain patency of the graft segment. Eighty-nine percent of the surgically treated patients required similar graft revisions. Two patients in the surgical group and one patient in the rt-PA-treated group had major complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of popliteal aneurysms. Trends in presentation, treatment, and results from 1952 to 1984.

Graft replacement was performed for 123 (77%) of 160 popliteal aneurysms evaluated at The Cleveland Clinic from 1952 to 1984, employing autogenous saphenous vein in 58 (36%), polytetrafluoroethylene in 19 (12%), and of historic interest, Dacron (12%) or arterial homograft (16%) in 46. The 10-year cumulative patency (CP) rate was 56% and the limb salvage (LS) rate was 83% following graft replacement, but late results were superior in patients who received vein bypass (CP, 94%; LS, 98%), in those who underwent revascularization before ischemic complications had occurred (CP, 92%; LS, 96%), and in those who recovered both pedal pulses (CP, 64%; LS, 96%). Long-term asymptomatic limbs were restored in 96%, 92%, and 89% of these subsets, respectively, compared with 65% of those receiving other graft materials (p = 0.00003), 59% of those with preoperative ischemic symptoms (p = 0.00001) and 68% of those regaining only an isolated popliteal pulse (p = 0.0326). These data indicate that popliteal aneurysms should be corrected by vein bypass to a patent tibioperoneal segment before spontaneous thrombosis or embolization eliminates the critical outflow bed.

Surgical management of aortic aneurysm and coexistent horseshoe kidney: Review of a 31-year experience * **

PURPOSE The coexistence of horseshoe kidney and aortic aneurysm poses a technical challenge to the vascular surgeon at the time of aneurysm repair. Clinical experience with this problem was reviewed to assess the results of treatment and to develop guidelines for the treatment of patients with horseshoe kidney and aortic aneurysm. METHODS From 1960 through 1991, 19 patients with associated horseshoe kidney (HSK) required repair of abdominal aortic aneurysm at the Cleveland Clinic. Seventeen men and two women, with a mean age of 67 years, underwent 16 elective and three urgent operations. The HSK was found before operation in 16 patients (84%), whereas the remaining three were discovered at operation. Computed tomography and intravenous pyelography were the most reliable means of preoperative diagnosis, whereas ultrasonography and aortography were less dependable. Mean size of abdominal aortic aneurysm was 6.1 cm. The mean preoperative creatinine level was 1.5 mg/dl. The surgical approach was transperitoneal in 16 patients and retroperitoneal in three. Division of the renal isthmus was avoided in all patients. RESULTS Renal artery anomalies were encountered in 14 patients (74%). Renal arterial continuity was established by a variety of techniques, including branch grafts or reimplantation into the aortic graft. Abnormal preoperative renal function was associated with a significantly increased risk for early postoperative hemodialysis (p = 0.02). There were three postoperative deaths, and the mortality rate for patients who required dialysis (67%) was significantly higher (p = 0.05) than that for patients who did not (6.3%). There were six late deaths at a mean follow-up interval of 57 months. CONCLUSIONS The most important aspect of HSK, therefore, is the appropriate surgical management of frequent renal artery anomalies. We currently believe this is best achieved with retroperitoneal exposure.