Mellick T. Sykes

Changing Pattern of Access Site Complications with the Use of Percutaneous Closure Devices

The authors report their experience with 15 cases of groin complications associated with the use of percutaneous closure devices following femoral arterial catheterization over a 2-year period. The complication rate was 1.7% for catheterizations in which a closure device was used. The 15 cases included 7 uncomplicated pseudoaneurysms (PSA), 3 infected pseudoaneurysms, 4 nonarterial groin infections (infected hematomas and/or abscesses), and 1 case of femoral artery occlusion. These complications presented at an average of 5 ±4 days postcatheterization. One patient with an infected PSA required a below-the-knee amputation. During the same time interval, there were no infectious complications in patients not receiving closure devices. We conclude that groin complications associated with such devices tend to present late and include a higher percentage of infections as opposed to complications occurring in patients not receiving closure devices. An aggressive surgical approach to these problems appears warranted.

Endovascular AAA repair in a patient with a horseshoe kidney and an isthmus mass.

PURPOSE To report the endovascular exclusion of an abdominal aortic aneurysm (AAA) in a patient with a horseshoe kidney and an isthmus mass with preservation of accessory renal vessels. CASE REPORT A 70-year-old man with a 5-cm AAA and renal cell carcinoma involving a horseshoe kidney was treated with an AneuRx bifurcated graft. Two accessory renal arteries believed to feed the isthmus mass were sacrificed, but 2 other accessory renal arteries from the left common iliac artery (CIA) were preserved by using an extension cuff to cover the aneurysmal left CIA distal to their origins. The right renal isthmus mass decreased in size on follow-up imaging. At 9 months, there was no endoleak evident on computed tomographic scans, and the aneurysm measured 4.8 cm. CONCLUSIONS The presence of accessory renal arteries in AAA patients with horseshoe kidneys should not automatically exclude them from consideration for endovascular repair. Creative stent-graft arrangements can be a treatment option.

Does the efficacy of dorsalis pedis artery bypasses vary among diabetic patients of different ethnic backgrounds

Hispanic patients suffer from a high rate of leg amputations, far beyond what would be expected from the high prevalence of diabetes in this population. This raises questions about the efficacy of bypass operations across ethnic lines. We focused this review on dorsalis pedis bypasses, as these are frequently performed in diabetic patients. We compared outcomes between Hispanics and non-Hispanics and sought to identify factors predictive of failure or complications. The authors conducted a retrospective review of 144 dorsalis pedis bypasses in 106 men and 29 women with a mean age of 62 years. Eighty-two percent were Hispanic; 96% of cases were done for tissue loss, and 4% for rest pain. Twenty-five percent of patients experienced perioperative complications; these were more frequent in non-Hispanics than Hispanics (40% vs 22%, p = 0.05). The most frequent complications were wound related (11%). The 30-day mortality was 1.5% and 30-day graft thrombosis was 5%. Follow-up ranged from 1 to 62 months and averaged 12 months. Eighty-one percent of the limbs at risk were saved, although 36% of cases required minor foot amputations. Estimated primary graft patency was 68% at 30 months. The 30-month Kaplan-Meier curves for primary patency, assisted patency, and limb salvage were not statistically different between Hispanics and non-Hispanics (p > 0.4). Grafts that remained patent had higher duplex-derived intraoperative flow velocities in the dorsalis pedis artery than grafts that eventually failed (121 +/-69 vs 74 +/-26 cm/sec, p = 0.02). In grafts that remained patent, dorsalis pedis velocity decreased from the perioperative period to the 8 to 12 weeks time point, whereas no change was seen in grafts that eventually failed (mean decline of 48 +/-76 vs 1 +/-58 cm/sec, p = 0.02). No other factors were predictive of graft failure. The results of dorsalis pedis bypass in Hispanic patients compare favorably to those seen in other ethnic groups. This suggests that other factors must account for the high amputation rates seen in Hispanics, such as a frequent occurrence of nonreconstructible disease or unaccounted for cardiovascular risk factors. The usefulness of duplex-derived flow velocities in the dorsalis pedis to predict long-term graft patency warrants further investigation.

Lower extremity bypass graft revision in diabetics

Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is frequently required in diabetic patients. The authors evaluated (1) the value of routine angiography before graft revision in diabetics, (2) factors that predict patients in whom angiography alters management, and (3) the incidence of recurrent stenosis and factors that might predict it. Forty-two infrainguinal primary vein bypasses undergoing primary revision were retrospectively studied. The initial graft stenosis was detected at a mean of 1 1.5 ±3.6 months after the original bypass. Angiograms were obtained in 38 cases, revealing additional findings in 29 of 38 cases (76%), with a resultant alteration of the operative plan in 27 cases (71%). The most frequent additional angiographic finding was the identification or localization of a lesion in the inflow or outflow tracts (18 of 27 cases). Cases where the angiogram altered the management plan had a mean systolic velocity ratio across the stenosis (Vr) of 7.3 ±6.1, versus a Vr of 4.8 ±1.3 for cases where the angiogram did not alter the management plan (p < 0.04). Duplex scanning identified 4 lesions that were not seen on angiography; 3 of 4 were confirmed as webs at surgery. Twenty of 42 grafts (48%) developed recurrent stenoses at a mean of 4.9 ±3.8 months from initial revision. Restenosis occurred in 69% of female limbs as compared to 38% of male limbs (p = 0.06). Recurrent stenosis was not a predictor of ultimate graft failure, unless left untreated. Four of 10 untreated grafts ultimately failed. A total of 9 of the 42 grafts eventually failed (21%), leading to 3 amputations (7%). The authors conclude that failing infrainguinal bypass grafts identified by duplex in diabetics should undergo a detailed angiographic evaluation. This frequently leads to an alteration in the management plan, especially in the presence of a high Vr across stenoses. High rates of limb salvage (93%) and assisted primary graft patency (79%) despite a high recurrent stenoses rate (48%) justify routine duplex surveillance, preoperative angiography, and aggressive graft revision in diabetic patients with infrainguinal grafts.

Efficacy of infrainguinal bypass for limb salvage in young diabetic patients

The efficacy of infrainguinal bypass for limb salvage in young diabetic patients has not been well established. The purpose of this study is to determine the intermediate-term results (patency and limb salvage) of infrainguinal revascularization carried out for limb salvage (rest pain or ulceration) in young (<50 years old) diabetic atherosclerotic patients. Thirty-nine bypasses in 31 patients with a mean age of 44 years were retrospectively reviewed. There were no perioperative deaths. Minor or major complications occurred in 23% of cases. By life table analysis, the 18-month primary patency rate was 60+/-11%, assisted primary patency rate was 78+/-9%, and limb salvage rate was 71+/-9%. Most major amputations (five of nine) were required in patients with functional bypasses, either because of persistent infection or failure of wound healing. The presence of severe stenoses (>70%) in all three major named foot vessels (dorsalis pedis, medial and lateral plantar arteries) was associated with a high likelihood of limb loss despite a patent bypass (p<0.05). We could not identify any other factors statistically predictive of thrombosis, amputation, or the need for graft revision. Infrainguinal revascularization in this patient population can be carried out with acceptable limb salvage rates. However, patients should be made aware of the high incidence of amputation regardless of the success of the revascularization procedure, particularly in the presence of severe occlusive disease within the foot.

Dual-inflow great vessel aneurysm: Delayed presentation after penetrating trauma

Aneurysms constitute uncommon sequelae of injuries to the thoracic outlet. Most such aneurysms are secondary to blunt trauma and usually involve the great vessels at their take-off from the aortic arch. Penetrating injuries are more often identified in the more distal vessels and only very rarely present as pseudoaneurysms. Reported here is a single case of a chronic posttraumatic pseudoaneurysm arising from both the right common carotid artery and the right subclavian artery. The workup and surgical approach provide practical lessons, complemented with illustrations that aid in the understanding of the case. It is an unusual case because of the dual-inflow nature of the aneurysm.

Autologous Superficial Femoral Vein for the Repair of Suprarenal Mycotic Aneurysms: A Preferred Conduit? A Case Report

The authors report a patient who presented with a ruptured mycotic aneurysm that destroyed the posterior segment of the suprarenal perimesenteric aorta. Initial in-line repair with a rifampin-soaked Dacron prosthetic patch failed 14 days postoperatively with recurrent hemorrhage. At reoperation, the aorta was repaired with a superficial femoral/popliteal vein interposition graft; a segment of superficial femoral/popliteal vein was also used in-line to revascularize the superior mesenteric and celiac arteries. The patient survived with no evidence of recurrence at 8 months postoperatively.