Luke S. Erdoes

Carotid patch angioplasty: Immediate and long-term results

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

Popliteal vascular compression in a normal population

PURPOSE Positional popliteal artery obstruction is believed to be an important factor contributing to popliteal artery entrapment syndromes. This study was undertaken to define the positional anatomy and physiologic condition of the vessels in the popliteal fossa in groups of highly trained and normally active young men and women. We postulate that at least some symptom-free individuals can occlude the popliteal artery with leg positioning. METHODS Seventy-two limbs were evaluated in 36 subjects. Symptom-free subjects were recruited in four groups: normally active men, normally active women, male competitive runners, and female competitive runners. All subjects underwent noninvasive testing that included resting segmental limb pressures and Doppler waveforms and color-flow duplex imaging with the leg in the neutral position and then with knee extension with active and passive dorsiflexion and plantar flexion of the foot. Subjects unable to occlude the popliteal artery with positioning were then exercised, and studies were repeated. Magnetic resonance imaging, with magnetic resonance angiography, was conducted on 14 subjects, with each leg studied in the neutral position and with active positioning. RESULTS Positional popliteal arterial occlusion occurred in 38 of 72 limbs (53%). No intergroup comparisons were statistically significant. The response of each leg was symmetric in 89% of subjects. No subject who could not occlude the popliteal artery at rest was able to do so with exercise. Magnetic resonance imaging disclosed normal anatomy in all subjects and showed the location of popliteal occlusion to be at the level of the soleal sling, with positional compression by the soleus muscle, the lateral head of the gastrocnemius, the plantaris, and popliteus muscles. CONCLUSION Popliteal arterial occlusion can be induced in 53% of subjects with simple leg positioning caused by myofascial compression. This must be considered when evaluating patients for intervention on the basis of physiologic testing of the popliteal vessels.

Critical carotid artery stenosis: Diagnosis, timing of surgery, and outcome

PURPOSE Patients with critical carotid artery stenoses have been considered to be at high risk for carotid artery occlusion necessitating urgent or emergency endarterectomy once the stenosis is identified. Included in this group of patients are those with carotid string sign or atheromatous pseudoocclusion (APO). This review was conducted to determine the impact of the severity of stenosis including APO on the treatment and outcome of patients undergoing carotid endarterectomy. METHODS The records of 203 consecutive carotid endarterectomies performed in 197 patients were reviewed in detail. Patients were stratified into a critical stenosis group (80% to 99% diameter) and noncritical stenosis group based on noninvasive vascular laboratory and carotid arteriography results. Comparisons were performed of demographic data, atherosclerotic risk factors, carotid artery disease presentation, interval between arteriography and endarterectomy, operative details, and surgical results between the critical and noncritical groups and between patients in the critical group with and without APO. RESULTS Carotid endarterectomies were performed on 91 critical carotid artery stenoses and 112 noncritical stenoses. The groups did not differ significantly with regards to demographics, risk factors, carotid artery disease presentation, mean back pressure, and operative use of shunt or patch closure. For the critical group the interval between arteriography and endarterectomy was 8.63 +/- 2.38 days compared with 9.64 +/- 2.14 days for the noncritical group (mean +/- SEM, p = 0.75). No patient in either group progressed to occlusion in the interval between arteriography and endarterectomy. Perioperative strokes occurred in two patients (2%) in the critical group and four patients (3.6%) in the noncritical group (p = 0.09). Likewise, no significant difference was demonstrated in these variables when comparing patients with critical carotid artery stenosis and APO with those without APO. CONCLUSIONS The presence of a critical carotid artery stenosis including APO did not impact on the treatment or outcome of patients requiring endarterectomy nor did it imply the need for emergency intervention to prevent thrombosis. Surgical intervention can proceed after evaluation and optimization of comorbid conditions without undue concern for interval thrombosis.

The relative contributions of carotid duplex scanning, magnetic resonance angiography, and cerebral arteriography to clinical decisionmaking: A prospective study in patients with carotid occlusive disease

PURPOSE Recent reports suggest that 80% to 90% of patients can safely undergo carotid endarterectomy on the basis of duplex scanning alone without cerebral angiography. Other investigators have recommended that a complementary imaging study such as magnetic resonance angiography (MRA) also be obtained. METHODS We prospectively evaluated 103 consecutive patients with carotid occlusive disease. Eighty percent of patients were symptomatic. All 103 patients underwent duplex scanning and arteriography. Additional noninvasive tests included computed tomography, magnetic resonance imaging, and MRA in 50%, 56%, and 48% of patients, respectively. At a multispecialty conference all studies except angiograms were reviewed, and a treatment decision was made by a panel of attending vascular surgeons, neurosurgeons, and neurologists. The cerebral angiograms then were reviewed and changes made to final treatment plans were noted. RESULTS After review of noninvasive studies, 30 of 103 of patients (29%) were believed to require arteriography because of diagnostic uncertainty of carotid occlusion in three patients, suggestion of nonatherosclerotic disease in four, suggestion of proximal disease in two, suboptimal noninvasive studies in one, and uncertainty of therapy despite good-quality noninvasive studies in 20 patients primarily with borderline stenoses and unclear symptoms. In 10 of these 30 patients (33%) management decisions were changed on the basis of angiogram results. Of the remaining 73 patients (71%) in whom the panel felt comfortable proceeding with operative or medical therapy without angiography, only one patient (1.4%) would have had management altered by results of angiography. MRA results concurred with duplex findings in 92% of studies, but did not alter management in any patient. CONCLUSIONS In patients with good-quality duplex images, focal atherosclerotic bifurcation disease, and clear clinical presentation, treatment decisions can be made without arteriography. In 30% of patients angiography is useful in clarifying decisionmaking. MRA is unlikely to influence management decisions and is thus rarely indicated.

Prospective evaluation of peripheral vascular disease in heart transplant recipients

PURPOSE Retrospective reviews suggest that the progression of peripheral vascular disease (PVD) may be accelerated in heart transplant recipients. This study was undertaken to determine the incidence and to identify those risk factors that may be associated with the development or progression of PVD in these patients. METHODS Between January 1990 and December 1993 a prospective vascular screening protocol including abdominal ultrasonography, Doppler-derived ankel-brachial pressure indexes (ABI), and carotid artery duplex imaging was added to the routine preoperative and annual postoperative evaluation of 239 heart transplant recipients. RESULTS Thirty-one significant vascular lesions were detected in 10% (24 of 239) of patients 52 +/- 9 years of age at a mean of 3.2 years after transplant. The distribution of lesions included carotid artery stenosis (11), femoropopliteal occlusive disease (10), aortoiliac occlusive disease (five), aortic aneurysm (four), and renal artery stenosis in one patient. Revascularization procedures were performed in 12 (50%) patients (carotid endarterectomy (four), aortobifemoral bypass grafting (three), abdominal aortic aneurysm repair (two), transluminal angioplasty (two), splenorenal bypass (one), and femorotibial bypass grafting (one)). One patient with diabetes mellitus (DM) was found to have noncompressible vessels during pretransplant evaluation. An additional 26 patients (11%), seven with DM, had noncompressible vessels in the lower extremities during the follow-up period. Logistic regression analysis revealed that the development of posttransplant PVD was associated with smoking (p < 0.05) and ischemic cardiomyopathy as an indication for transplantation (p < 0.05). The development of noncompressible vessels was associated with younger age (p < 0.05) and the presence of diabetes (p < 0.05). CONCLUSION Posttransplant peripheral vascular disease occurred in 10% of heart transplant recipients and is associated with pretransplant ischemic cardiomyopathy and smoking. A previously unrecognized subgroup of patients who have noncompressible vessels after operation is described. If the long-term survival of the heart transplant recipient is to be improved, routine follow-up to identify and treat those patients at greater risk appears justified.

Ruptured Abdominal Aortic Aneurysm: Factors Affecting Survival and Long-Term Results

Although elective resection of an abdominal aortic aneurysm (AAA) is now a safe operation, the mortality related to a ruptured abdominal aortic aneurysm (rAAA) remains significant. To evaluate factors affecting survival and the long- term results after rAAA, a ten-year review of 47 patients was performed. The operative mortality rate was 43% (20/47) compared with 2.6% for 147 elective AAA patients during this period. Factors adversely affecting survival were blood pressure <90 mmHg on arrival to the hospital, perioperative cardiac arrest, delay in time from diagnosis to treatment > six hours, age > seventy-five years, massive transfusion, and free intraperitoneal rupture. In follow-up extending to five years the survivors of rAAA at one (92%) and five (53%) years had no discernible differences in quality of life or long- term survival compared with age- and sex-matched patients who had elective AAA resection during the same time interval. When an rAAA occurs and any three of the adverse variables noted above are present, the mortality rate exceeds 90%. These patients remained ventilator dependent and in the ICU from one to sixty-seven days, accumulating hospital charges from

Prophylactic Interruption of the Inferior Vena Cava: Immediate and Long-Term Results

7,000 to

Endoscopic vein harvest in peripheral vascular surgery.

214,000. It appears that the most effective means of reducing mortality statistics in this inordinately low-salvage, yet high-cost sub group of patients, is to prevent rupture of an AAA by elective resection.

Regarding “Spontaneous popliteal artery dissection: a case report and review of the literature”

To determine the effects of prophylactic interruption of the inferior vena cava (IVC) the hospital course of 340 patients who underwent aortic operations with placement of a Moretz IVC clip between 1980 and 1988 was removed: 175 patients had had abdominal aortic aneurysm resection; 143, aortobifemoral by pass; and 22, aortobiiliac endarterectomy or bypass. There were no complica tions related to placement of the IVC clip. After operation, any clinical suspicion of deep vein thrombosis (DVT) or pulmonary embolus (PE) was docu mented by phlebography or pulmonary arteriography, respectively. In the im mediate postoperative period ( < thirty days), only 2 (0.5%) patients had a PE and 10 (2.9%) a DVT. For long-term follow-up extending to eight years (mean ± 42.8 months), 308 patients were available. During long-term follow-up, 2 (0.6%) patients had a PE and 7 (2.2%) a DVT. Limb edema without evidence of DVT occurred in another 7 (2.2%) patients. B-mode ultrasonography of the IVC was performed in 163 patients. The IVC was clearly patent in all but 5 (3%): 1 had had a documented PE in the immediate postoperative period, and the other 4, an asymptomatic occlusion of the IVC during late follow-up. Prophylactic IVC interruption in aortic surgical patients appears not to cause IVC thrombosis, to initiate DVT, or to cause chronic venous insufficiency. The results indicate that it is a safe method of decreasing the incidence of PE, without increasing operative morbidity.