Linda G. Canton

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: A preliminary report from the North American registry

PURPOSE The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency. METHODS Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996. RESULTS SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120). CONCLUSIONS The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease

OBJECTIVES The purpose of this study was to evaluate the role of endovascular and open surgical reconstructions in patients with superior vena cava (SVC) syndrome caused by nonmalignant disease. METHODS Clinical data from 32 consecutive patients who underwent endovascular or open surgical reconstruction of central veins because of symptomatic benign SVC syndrome between November 1983 and June 2001 were retrospectively reviewed. RESULTS The study included 17 male and 15 female patients (mean age, 38 years; range, 5-69 years). Presenting symptoms were head fullness (n = 26), dyspnea or orthopnea (n = 23), headache (n = 17), or dizziness (n = 11); physical signs were head swelling (n = 31), chest wall collateral vessels (n = 29), facial cyanosis (n = 18), or arm swelling (n = 17). Etiologic factors included mediastinal fibrosis (n = 19), indwelling catheter (n = 8), idiopathic thrombosis (n = 4), or post-surgery (n = 1). Two patients were heterozygous for factor V Leiden; 1 patient had antithrombin III deficiency. Twenty-nine patients underwent surgical reconstruction with 31 bypass grafts: spiral saphenous vein (n = 20), superficial femoral vein (n = 4), human allograft (n = 1), or expanded polytetrafluoroethylene (ePTFE, n = 6). Eleven patients underwent percutaneous transluminal angioplasty or stenting; 3 primary and 8 secondary endovascular procedures were performed to treat graft stenosis (n = 7) or occlusion (n = 1). There were no early deaths. Five early graft failures in 3 ePTFE grafts and 2 bifurcated vein grafts (thrombosis, n = 4; stenosis, n = 1) were successfully treated with open surgical revision. Over a mean follow-up of 5.6 years (range, 0.4-16.6 years) in surgical patients, 17 additional secondary interventions were performed in 8 patients, 14 endovascular and 3 surgical. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were 63%, 79%, and 85%, respectively, at 1 year, and 53%, 68%, and 80%, respectively, at 5 years. Graft patency was significantly higher in vein grafts compared with ePTFE grafts (P =.02). Mean follow-up after percutaneous transluminal angioplasty or stenting was 3.1 years (range, 1 day-11.7 years). Twelve secondary endovascular interventions were performed in 6 patients (primary group, 3 of 3; secondary group, 3 of 9 grafts in 8 patients) to maintain patency in 11 of 12 reconstructions. Mean follow-up in the entire patient cohort was 5.3 years (range, 0.4-16.6 years). In 79% of patients symptoms had resolved or were significantly improved at last follow-up. CONCLUSIONS Surgical treatment of benign SVC syndrome is effective over the long term, with secondary endovascular interventions to maintain graft patency. Straight spiral saphenous vein graft remains the conduit of choice for surgical reconstruction, with results superior to those with bifurcated vein and ePTFE. Endovascular treatment is effective over the short term, with frequent need for repeat interventions. It does not adversely affect future open surgical reconstruction and may prove to be a reasonable primary intervention in selected patients. Patients who are not suitable for or who fail endovascular intervention merit open surgical reconstruction.

Surgical technique and preliminary results of endoscopic subfascial division of perforating veins.

PURPOSE Direct surgical ligation of incompetent perforating veins has been reported to effectively treat severe chronic venous insufficiency. It is associated, however, with significant wound complications. We evaluate our early experience with endoscopic subfascial division of the perforating veins. METHODS From August 5, 1993, to December 31, 1994, 11 legs in nine patients (five male and for female) were treated with endoscopic subfascial division of perforating veins. Nine of the 11 legs had active or recently healed venous ulcers. Mean duration of the ulcerations was 5.6% years. Standard laparoscopic equipment with 10-mm ports was used to perform clipping and division of medial perforating veins through two small incisions made just below the knee, avoiding the area of ulcer and lipodermatosclerosis. Carbon dioxide was insufflated at a pressure of 30 mm Hg into the subfascial space to facilitate dissection, and a pneumatic thigh tourniquet was used to obtain a bloodless operating field. Concomitant removal of superficial veins was performed in eight limbs. Mean follow-up was 9.7 months (range, 2 to 13 months). RESULTS A mean of 4.4 perforating veins (range, 2 to 7) were divided; tourniquet time averaged 58 minutes (range, 30 to 72). Wound infection of a groin incision and superficial thrombophlebitis were early complications; each occurred in one patient. In seven legs the ulcer healed or did not recur and symptoms resolved. In three legs, the ulceration improved, and in one it was unchanged. CONCLUSIONS Endoscopic subfascial division of perforating veins seems to be a safe technique, with favorable early results obtained in a small number of patients. This preliminary experience supports further clinical trials to evaluate this technique.

Endovascular repair of abdominal aortic aneurysms: initial experience with 100 consecutive patients.

OBJECTIVE To review early results of endovascular repair of abdominal aortic aneurysms (AAAs). PATIENTS AND METHODS The first 100 patients who underwent endovascular repair of AAA (EVAR) between June 26,1996, and October 31, 2001, at the Mayo Clinic in Rochester, Minn, were studied retrospectively to evaluate technical success, freedom from reinterventions, and early clinical outcome. RESULTS A total of 89 men and 11 women (mean +/- SD age, 76 +/- 7 years; range, 47-92 years) underwent EVAR. The procedure was successful in 97 patients. There was no early death. Major complications occurred in 25 patients. The 30-day technical success rate was 86% (95% confidence interval [CI], 77%-92%). The median intensive care unit stay was 1 day (range, 1-15 days), and the median hospital stay was 3 days (range, 1-35 days). Median follow-up was 7 months (range, 1-60 months). Endoleak (incomplete seal of the endovascular graft) at discharge was observed in 14 patients; 13 developed endoleak during follow-up. There were 23 reinterventions, 65% of which were percutaneous procedures. One aneurysm ruptured at 5 months, but the patient was successfully treated by open repair. Primary and secondary graft patency rates at 1 year were 83% (95% CI, 74%-93%) and 94% (95% CI, 87 %-99%), respectively. The freedom from reintervention rate at 1 year was 71% (95% CI, 59%-84%), with an overall success rate from EVAR of 92% (95% CI, 84%-100%). There were no differences in early patency, reinterventions, and success rates between unibody and modular devices. CONCLUSION EVAR can be performed with high technical success and low mortality rates; however, nonfatal complications and catheter-based reinterventions are frequent, and EVAR may not prevent aneurysm rupture. Although stent graft repair for high-risk patients is appealing, current data are insufficient to support EVAR as the preferred treatment of AAAs.

The benefits of secondary interventions in patients with failing or failed pedal bypass grafts

BACKGROUND Autogenous bypass grafts to pedal arteries have successfully salvaged limbs and restored function in patients with critical ischemia. The benefits of secondary interventions to save failing or already failed grafts remains uncertain. METHODS A retrospective analysis was made of consecutive pedal bypasses performed between 1987 and 1998. Patency and limb salvage by life-table analysis and variables affecting outcome were compared with the log-rank test. RESULTS Two hundred thirteen patients, 144 males, 69 females (mean age 68 years, range 30 to 91) underwent pedal bypass grafting in 228 limbs using autogenous vein grafts (nonreversed saphenous vein, n = 190; reversed, n = 15; composite, n = 23). One-hundred fifty-seven patients were diabetic, 34 had renal insufficiency (serum creatinine >2.0), and 14 were on dialysis. Gangrene or ulceration were present in 224 patients, rest pain in 24. Cumulative primary and secondary patency rates were 57% and 67% at 5 years. Limb salvage was 78% at 5 years. Secondary interventions in 46 patients included patch angioplasty/surgical revision (n = 28), thrombectomy (n = 15), thrombolysis (n = 11), and balloon angioplasty (n = 6). Patency in 19 of 26 (73%) failed grafts and in 19 of 20 (95%) failing grafts could be restored initially. Cumulative 2-year patency and limb salvage rates following reinterventions were 36% and 58%, respectively. Patency rates and limb salvage for failed grafts (7%, 44%) were significantly worse than those for failing grafts (81%, 77%; P <0.0001, P <0.05, respectively). All patients with renal insufficiency who underwent reinterventions for failed or failing grafts required major amputation within 1 year (P <0.0001 versus those without renal insufficiency). CONCLUSION Autogenous pedal bypass grafts are durable operations with excellent long-term patency and limb salvage rates. Revision of failing grafts has been effective using both endovascular and surgical techniques. Failed grafts have poor long-term patency and moderate limb salvage rates, and our data do not justify secondary procedures to attempt to save failed grafts in patients with renal insufficiency.

Aortic Reconstruction in Kidney Transplant Recipients

Renal transplantation has increased the longevity of patients with uremia. An increasing number undergo aortic reconstruction, which exposes the transplanted kidney to ischemic injury. To evaluate the risk for renal failure, loss of the transplant, and methods of renal protection, we reviewed our experience. Clinical data were reviewed for 10 consecutive patients (7 men, 3 women; mean age 52.7 years [range 32 to 75 years]) with a transplanted kidney who underwent aortic reconstruction between 1977 and 1994 at our institution. Mean interval between renal transplantation and aortic reconstruction was 5.9 years (range 1 month to 12.7 years). Seven patients required emergency repair because of dissection (2 patients), aneurysm rupture (4 patients), or symptomatic aneurysm (1 patient); three underwent elective repair. Reasons for reconstruction included aortic dissection (2 patients), aneurysm of the descending thoracic (2 patients), thoracoabdominal (1 patient), or abdominal aorta (3 patients), and aortoiliac occlusive disease (2 patients). Patients with thoracic or thoracoabdominal reconstructions underwent repair with atriofemoral, aortofemoral, or femorofemoral shunt placement or bypass. Of the five abdominal aortic reconstructions, the kidney was protected with aortofemoral shunt placement in one patient and cold renal perfusion in three. In two of them, topical cooling of the kidney also was used. One patient with acute aortic dissection died at 39 days as a result of respiratory failure. Loss of the recently transplanted kidney was caused by acute rejection. One patient had a transient increase in serum creatinine concentration. Eight had no worsening of renal function, and none of the nine survivors lost the transplanted kidney. We conclude that aortic reconstruction can be safely performed in kidney transplant recipients. Patients in whom thoracic or thoracoabdominal aortic reconstruction was required were protected with an atriofemoral or aortofemoral bypass or shunt. Patients undergoing abdominal aortic reconstruction did well when cold renal perfusion with or without local cooling of the transplant was used for renal protection. Transplanted kidneys appeared to tolerate ischemic injury similarly to native kidneys.

Pulmonary embolism after endovenous thermal ablation of the saphenous vein

Pulmonary embolism (PE) after venous procedures is fortunately rare. Our goal was to analyze the data of patients who developed PE after endovenous thermal ablation and phlebectomy for varicose veins and to review the literature on this subject. We report on three patients who developed PE after radiofrequency ablation of the great saphenous vein and mini phlebectomy for symptomatic primary lower-extremity varicose veins. Early postoperative duplex scans confirmed successful closure of the great saphenous vein in all. One patient presented with chest pain and dyspnea, one with blood-tinged sputum, and the third with symptoms of saphenous thrombophlebitis. Two patients had PE from the saphenous vein thrombus and the third had gastrocnemius vein thrombosis extending into the popliteal vein. One had previous deep vein thrombosis. Computed tomography of the chest confirmed PE in all. Two patients were treated with anticoagulation, but the third patient with small PE declined such treatment. One patient underwent temporary inferior vena cava filter placement because of recurrent PE. In conclusion, PE is very rare but it can occur after endovenous thermal ablation of lower-extremity varicose veins. Selective thrombosis prophylaxis and preoperative counseling of the patients about signs and symptoms of deep vein thrombosis and PE are warranted for early recognition and rapid treatment.

Subfascial Endoscopic Perforator Vein Surgery with Gas Insufflation

Progress in minimally invasive techniques used for abdominal surgical procedures has been primarily responsible for the renewed interest in perforator vein surgery. Initial endoscopic procedures applied single lumen endoscope or mediastinoscope for viewing and as working channel, sometimes without the benefits of video equipment and appropriate endoscopic stapling devices.1–4 Improvement in the single scope concept adding video equipment and new instrumentation was inevitable, and currently used techniques5–7 are discussed in detail in Chapters 12 and 15. Laparoscopic instrumentation using two ports has been the new generation of tools in the evolution of perforator surgery. Carbon-dioxide insufflation into the subfascial space was added to improve visibility and to enlarge the working space. We started the use of gas insufflation early in our experience, recognizing its advantages over infusion of water in the subfascial space as recommended initially.8

Hybrid intervention for treatment of the nutcracker syndrome

Nutcracker syndrome is a rare anomaly resulting from compression of the left renal vein between the aorta and the superior mesenteric artery. Open and endovascular interventions have both been performed to relieve the compression. Each of these interventions has strengths and weaknesses. We report two patients in whom a hybrid approach was adopted in the process combining the strengths of each intervention while reducing potential complications.

Results of the North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry

Since the mid-1980s, considerable experience has accumulated in Europe with different endoscopic techniques to treat perforator vein incompetence.1–5 Several groups in the United States and Australia also recognized the advantages of endoscopic procedures and used existing equipment made available by progress in minimally invasive non-vascular surgical technology.6–10 Recognizing the benefits of perforator interruption and the problems of wound complications and prolonged hospitalization associated with the open procedures, a group of surgeons interested in the care of patients with advanced chronic venous disease decided to evaluate the minimally invasive, endoscopic Linton operation in a multicenter trial. To embark on a series of studies, the registry concept was embraced first to rapidly accumulate useful clinical information.