Steven J. Burnham

Summary of cases of adventitial cystic disease of the popliteal artery.

Adventitial cystic disease of the popliteal artery is explored. The results of correspondence with authors reporting this condition are elaborated upon. This has provided an opportunity to discuss the history of the condition, the findings in 115 cases which have come to the attention of the Correspondence Office dealing with this entity, and the results of treatment. A discussion of the suspected etiology of the condition is presented. The condition remains one of unknown etiology which can be treated by cyst evacuation or aspiration when the popliteal artery is patent and which is best treated by arterial reconstruction when the artery is occluded. The results of such treatment are good but are dependent upon technical excellence of the operative procedure.

Prospective randomized comparison of surgical versus endovascular management of thrombosed dialysis access grafts

PURPOSE Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function. METHODS One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty. RESULTS Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored (p = NS). The postoperative graft function rate was significantly better in the surgical group (p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis (p < 0.05). CONCLUSIONS Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops.

Lower extremity amputation: The control series

Although various techniques to determine amputation level have become available, obvious clinical factors may yet identify patients in whom a major amputation is unlikely to heal. We have analyzed the association of multiple clinical factors with the morbidity of 1028 consecutive amputations performed in 786 patients during a 13-year period. The overall operative mortality rate was 7% (57 of 786 patients). Cardiac complications were the leading cause of death (43%). In the 729 patients surviving operation, 345 above-knee amputations (AKAs) and 626 below-knee amputations (BKAs) were performed. After operation, 15.4% of these amputations failed to heal and required proximal revision. The AKA failure rate was 9% and the BKA failure rate was 19%. Significantly higher failure rates were noted in whites, nondiabetics, and those patients with heart disease. It is concluded that major amputation continues to be associated with significant morbidity and mortality rates despite changes in perioperative care and surgical technique. Common clinical characteristics indicate high-risk patients in whom a BKA is unlikely to heal and who may benefit from prospective attempts to determine amputation level.

Extrathoracic reconstruction of arterial occlusive disease involving the supraaortic trunks

PURPOSE The purpose of this study was to review the various extrathoracic reconstruction options in patients with occlusive disease of the supraaortic trunks and to define the efficacy of these procedures in maintaining graft patency and relieving symptoms. METHODS Forty-four consecutive patients underwent 47 extrathoracic bypass procedures of the supraaortic trunks for correction of symptomatic subclavian (SCA), common carotid (CCA) or innominate (INA) artery occlusive disease between July 1975 and May 1994. SCA stenosis (n = 27) was associated with upper extremity claudication (55%), vertebrobasilar insufficiency (15%), or both (30%). CCA stenosis (n = 14) was accompanied by hemispheric symptoms in 86% and global ischemia in 14%, whereas INA stenosis (n = 3) was associated with transient ischemic attacks (67%) and right arm ischemia (33%). RESULTS SCA revascularization included carotid-subclavian or carotid-axillary bypass (n = 19), axilloaxillary bypass (n = 8), and subclavian-carotid transposition (n = 3). CCA reconstructions included subclavian-carotid (SC) bypass (n = 13) and carotid-carotid bypass (n = 1). INA procedures included three axilloaxillary bypasses. Six patients had an associated carotid endarterectomy, and three underwent concomitant vertebral artery transpositions. Intraluminal shunts were not routinely used. Vein was used as a conduit in five procedures, and a prosthetic graft (23 Dacron, 16 polytetrafluoroethlyene) was used in the remainder. The average postoperative intensive care unit and hospital and hospital stay were 1 and 5 days, respectively. Follow-up was available in 43 of 44 patients (mean = 26.2 months). The perioperative mortality rate was 2.2% (one axilloaxillary). There were five graft occlusions in procedures involving the axillary artery (3 of 11 axilloaxillary, 2 of 7 carotid-axillary) as compared with one of 29 thromboses when the operation was confined to the supraclavicular fossa (p < 0.05) Relief of symptoms was achieved in all patients with patent grafts. There were no perioperative strokes in the series. Other complications included one brachial plexus neuropraxia (axilloaxillary) and four patients with phrenic nerve neuropraxia. CONCLUSION Extrathoracic revascularization of the supraaortic trunks is well tolerated and durable when operations are confined to the supraclavicular fossa and do not involve the axillary artery.

Carotid endarterectomy: a follow-up study of the contralateral non-operated carotid artery.

In a study of 103 patients surviving carotid endarterectomy, follow-up information was obtained from all patients over a period of time extending to four years. This was done so that better decisions could be made regarding recommendations for contralateral carotid surgery. In this follow-up study, only three patients had contralateral surgery. Three additional patients had events clearly in the territory supplied by the contralateral carotid artery, and no patient suffered a contralateral stroke. There were an additional four patients who suffered stroke in territory not supplied by the contralateral carotid artery. In addition, four patients experienced classical transient ischemic episodes referrable to the operated carotid artery and ten patients experienced nonclassical cerebral ischemia. Seven of the 103 patients died at times remote from the carotid surgery of nonstroke cause.

Descending thoracic aorta-to-iliofemoral artery bypass as an alternative to aortoiliac reconstruction

During the last 3 decades subcutaneous extraanatomic bypass, despite its limited durability, has been the favored alternative to infrarenal aortofemoral bypass. Meanwhile, the descending thoracic aorta has been scarcely used as an inflow source for aortoiliac reconstruction. Over the past 8 years we performed 16 bypasses from the descending thoracic aorta to the iliofemoral vessels for occlusive disease. Our experience combined with that found in the English-language literature totaled 141 patients. In 79 patients (56%) the indication for surgery was failure or infection of an abdominal aortofemoral graft. Previous abdominal operations, sepsis, radiation therapy, the presence of abdominal stomas, or an unsuitable infrarenal aorta were the indications in the remaining cases. The combined operative mortality rate was 6.4%. The life-table primary graft patency was 98% at 1 year, 88% at 2 years, and 70.4% at 5 years. Bypass from the descending thoracic aorta to the iliofemoral artery uses an inflow source superior to other extraanatomic reconstructions, does not require aortic cross-clamping, avoids the abdominal cavity, and places the graft remote to the skin and intestine. The operative mortality and patency rates compare favorably to those of other extraanatomic or remedial aortic reconstructions. Descending thoracic aorta to iliofemoral artery bypass is a superb alternative to abdominal aortofemoral bypass, carries a low mortality rate, has an excellent short-term patency, and features unique characteristics for long-term durability.

Quantitative analysis of continuous-wave Doppler spectral broadening for the diagnosis of carotid disease: Results of a multicenter study

This article reports the results of a multicenter study that compares 333 frequency analysis studies with the continuous-wave Doppler method with angiography. With receiver operating characteristic curves, the study documents the accuracy of the Doppler technique for the diagnosis of extracranial carotid arterial stenosis greater than 45% diameter reduction. It confirms the accuracy of the measurement of the maximal peak Doppler frequency and, in addition, shows that quantitative analysis of the instantaneous Doppler spectrum at peak systole by the measurement of the spectral broadening index is of diagnostic value. Likelihood ratios have been calculated with the use of curve-fitting techniques and it has been demonstrated how both the peak frequency and the spectral broadening index can be used together to improve the certainty of diagnosis. It is concluded that the probability that an individual patient has significant carotid arterial disease can be determined with the measurements of peak frequency and spectral broadening index from the continuous-wave Doppler spectral waveform.

Rifampin protection against experimental graft sepsis

The risk of infection in vascular prosthetic conduits appears to be greatest in the perioperative period and the organism most frequently found is Staphylococcus aureus. Previous work suggests that antibiotics must be chemically bonded to the material to resist rapid washout caused by the flow of blood through the graft. The exception to this is rifampin, which remains fixed in Dacron prostheses after passive addition of the agent to aliquots of blood used to clot the interstices of porous Dacron grafts. This characteristic of rifampin is presumed to be caused by its poor water solubility. This potential infection resistance was challenged in a standard model of a canine infrarenal aortic graft by intravenous infusion of S. aureus organisms (10(7)) in the perioperative period. The grafts of five animals were preclotted with 9 ml of autogenous blood plus 1 ml of rifampin (60 mg/ml). A second group had similar procedures with 1 ml of cefazolin (238 mg/ml) substituted for the rifampin, and a control group had 1 ml of saline solution added to the 9 ml aliquot of blood. The animals were killed at 3 weeks and examined for clinically apparent infection. Rings of the graft material were also removed aseptically and cultured. All five grafts preclotted with cefazolin had clinical and culture evidence of infection (S. aureus), as did the grafts of three of the five control dogs. None of the grafts preclotted with rifampin was infected (p less than 0.05). Addition of rifampin to the blood used to clot the graft interstices appears to be a simple way of imparting graft resistance to perioperative sepsis.

Management and outcome of chronic atherosclerotic infrarenal aortic occlusion

PURPOSE To evaluate the management and outcome of chronic atherosclerotic infrarenal aortic occlusion (IRAO), a review of 48 patients who were treated for angiographically documented IRAO between January 1980 and December 1994 was undertaken. Mean follow-up was 45 months. Mean age was 57 years (range, 33 to 88 years). Forty-seven patients were heavy smokers. Symptoms included claudication in 81%, rest pain in 25%, and tissue loss in 15%. Impotence was documented in 73% of men. Associated arterial disease included inferior mesenteric artery occlusion in 31 patients, renal artery stenosis or occlusion in 12, superior mesenteric artery stenosis in two, and celiac artery stenosis in one. METHODS Forty inflow procedures were performed, including 17 thoracobifemoral bypass (TBF) procedures, 15 aortobifemoral/iliac bypass (ABFI) procedures, and eight axillobifemoral bypass (AXBF) procedures. Eight patients were managed without surgery. The thoracic aorta was chosen as the inflow source in 17 patients because of previous abdominal aortic surgery in eight, poor status of the abdominal aorta in eight, and horseshoe kidney in one. RESULTS The overall operative mortality rate was 5%, and the perioperative morbidity rate was 18%. There was no statistical difference in perioperative mortality and morbidity rates among the operative groups. The five-year survival rate (life-table) for all IRAO patients was 67%. TBF and ABFI revascularization procedures yielded 5-year patency rates of 71% and 79%, respectively (p < 0.05). All eight patients who underwent AXBF died or had occluded grafts at 3 years after surgery. Two-year patency rates (life-table) for TBF, ABFI, and AXBF were 92%, 92%, and 44%, respectively. The AXBF patency rate was significantly inferior to those of TBF and ABFI (p < 0.05). Changes in ankle-brachial indexes after TBF or ABFI were similar, but were significantly greater than changes after AXBF (p < 0.05). Three patients in the nonoperative group died, and two underwent major amputation. Acute renal failure did not occur in our study population. Follow-up creatinine levels > 2.0 mg/dl were documented in three operative patients and in one nonoperative patient, and none required dialysis. CONCLUSIONS In patients who have IRAO, aorta-based inflow procedures are superior to AXBF both in hemodynamic outcome and in patency rates. Treatment of IRAO with TBF or ABFI yields similar long-term results; the descending thoracic aorta represents an excellent inflow alternative to the abdominal aorta. Clinically significant renal impairment is rarely associated with IRAO. Nonoperative management of IRAO is associated with an increased mortality rate and a high rate of limb loss.

Noninvasive determination of healing of major lower extremity amputation: the continued role of clinical judgment

Various tests are used preoperatively to differentiate patients who require an above-knee amputation (AKA) from those whose vascular supply is adequate to heal a below-knee procedure (BKA). This 15-month study of 109 amputations compared four of these methods: segmental Doppler systolic pressure measurements, transcutaneous oxygen measurement (tcPO2), fluorescein angiography, and skin thermometry. There were 66 BKAs (85% healed primarily) and 43 AKAs (93% healed primarily). The actual level of amputation was determined by the operating surgeon without consideration of the preoperative test results, and the incidence of healing was then related to the test parameters. The average skin temperature at the amputation site was higher (93.7 degrees F) in the group that healed primarily compared with those who required operative stump revision (89.9 degrees F) (p less than 0.001). The mean midcalf tcPO2 was also higher in the BKA group that healed (PO2 = 36.6 mm Hg) compared with those who failed (PO2 = 16.4 mm Hg) (p less than 0.001). Qualitative skin fluorescence was less successful in differentiating success from failure. Of the 63 BKAs that fluorescein predicted would heal, eight failed (13%). Doppler pressures at the thigh, popliteal, midcalf, or ankle level were unreliable in predicting healing of a BKA. Formulation of indexes relating absolute pressures to the brachial systolic pressure did not improve the value of this examination. From this review it is concluded that the skin temperature and tcPO2 obtained at the site of proposed amputation were the most reliable prognostic noninvasive examinations.(ABSTRACT TRUNCATED AT 250 WORDS)