Thomas C. Bower

Graft-related complications after abdominal aortic aneurysm repair: Reassurance from a 36-year population-based experience

PURPOSE Graft-related complications must be factored into the long-term morbidity and mortality rates of abdominal aortic aneurysm (AAA) repair. However, the true incidence may be underestimated because some patients do not return to the original surgical center when a problem arises. METHODS To minimize referral bias and loss to follow-up, we studied all patients who underwent AAA repair between 1957 and 1990 in a geographically defined community where all AAA operations were performed and followed by a single surgical practice. All patients who remained alive were asked to have their aortic grafts imaged. RESULTS Among 307 patients who underwent AAA repair, 29 patients (9.4%) had a graft-related complication. At a mean follow-up of 5.8 years (range, < 30 days to 36 years), the most common complication was anastomotic pseudoaneurysm (3.0%), followed by graft thrombosis (2.0%), graft-enteric erosion/fistula (1.6%), graft infection (1.3%), anastomotic hemorrhage (1.3%), colon ischemia (0.7%), and atheroembolism (0.3%). Complications were recognized within 30 days after surgery in eight patients (2.6%) and at late follow-up in 21 patients (6.8%). These complications were observed at a median follow-up of 6.1 years for anastomotic pseudoaneurysm, 4.3 years for graft-enteric erosion, and 0.15 years for graft infection. Kaplan-Meier 5- and 10-year survival free estimates were 98% and 96% for anastomotic pseudoaneurysm, 98% and 95% for combined graft-enteric erosion/infection, and 98% and 97% for graft thrombosis. CONCLUSIONS This 36-year population-based study confirms that the vast majority of patients who undergo standard surgical repair of an abdominal aortic aneurysm remain free of any significant graft-related complication during their remaining lifetime.

Mesenteric venous thrombosis: Still a lethal disease in the 1990s

PURPOSE This study was designed to evaluate progress in diagnosis, management, and clinical outcome of mesenteric venous thrombosis (MVT). METHODS We retrospectively reviewed the clinical course of 72 patients treated for mesenteric venous thrombosis between 1972 and 1993. RESULTS Fifty-three patients had acute and 19 had chronic mesenteric venous thrombosis. Fifty-seven patients had secondary mesenteric venous thrombosis; previous abdominal surgical procedure and hypercoagulable states were the most prevalent associated conditions. Computed tomography was abnormal in all patients who underwent this test for acute mesenteric venous thrombosis and in 93% of those who had chronic disease. Angiography diagnosed acute mesenteric venous thrombosis in five (72%) of seven patients. Acute mesenteric venous thrombosis presented most frequently as abdominal pain (83%), anorexia (53%), and diarrhea (43%). Thirty-three (75%) had symptoms longer than 48 hours. Thirty-four (64%) patients with acute mesenteric venous thrombosis underwent a surgical procedure. Bowel resection was necessary in 31 patients. One patient had unsuccessful mesenteric venous thrombectomy. Seven patients with acute mesenteric venous thrombosis underwent anticoagulation without a surgical procedure, and 12 were observed. All patients with chronic mesenteric venous thrombosis were observed; nine of the 19 underwent anticoagulation. The median delay in diagnosis for patients with acute mesenteric venous thrombosis was 48 hours and did not decrease during the last decade. Mesenteric venous thrombosis recurred in 19 (36%) patients. The 30-day mortality was 27%. Long-term survival of patients with acute mesenteric venous thrombosis was significantly worse than that of those with chronic disease (36% vs 83% survival at 3 years). The patients with acute mesenteric venous thrombosis who underwent anticoagulation with and without surgical procedure had improved survival when compared with the observed group. CONCLUSION Acute mesenteric venous thrombosis remains a lethal disease. Mortality has not improved in the last 22 years. Computed tomography is the most sensitive diagnostic test. Anticoagulation and surgical procedure enhanced survival in the acute subgroup. The underlying disease determined survival in chronic disease.

Hepatic artery aneurysm: factors that predict complications

OBJECTIVE We reviewed the Mayo Clinic experience with management and outcome of hepatic artery aneurysms (HAA). METHODS Retrospective review of charts for 306 patients with true visceral aneurysm diagnosed from 1980 to 1998 enabled identification of 36 patients (12%) with HAA. RESULTS Patients with HAA included 23 men and 13 women, with mean age of 62.2 years (range, 20-85 years). Most aneurysms were extrahepatic (78%) and single (92%). Mean aneurysm diameter at presentation was 3.6 cm (range, 1.5-14 cm). Five aneurysms had ruptured (14%), and four were symptomatic (11%). Mortality from rupture was 40%. Of the 9 patients with ruptured or symptomatic aneurysms, 2 patients had multiple HAA, 3 patients had fibromuscular dysplasia, and 2 patients had polyarteritis nodosa. All five HAAs that ruptured were of nonatherosclerotic origin (P =.001). Fourteen patients (39%) underwent elective procedures, including excision with vein graft (n = 7), excision with dacron graft (n = 3), excision alone (n = 2), and percutaneous embolization (n = 2). Two vein grafts and one dacron graft became occluded within 1 year. Nonoperative management was elected in 22 patients (61%) with mean aneurysm diameter 2.3 cm (range, 1.5-5 cm). No complications related to the aneurysm occurred during mean follow-up of 68.4 months (range, 1-372 months). Aneurysm growth was identified in 27%, the greatest being 0.8 cm over 34 months. CONCLUSIONS HAA are at definite risk for rupture (14%). Risk factors for rupture include multiple HAA and nonatherosclerotic origin. Patients with symptomatic aneurysms or any of these risk factors should be considered for intervention.

Replacement of the inferior vena cava for malignancy: an update.

OBJECTIVES Resection and replacement of the inferior vena cava (IVC) to remove malignant disease is a formidable procedure. Since our initial report with IVC replacement for malignancy, we have maintained an aggressive approach to these patients. The purpose of this review is to update our experience with regard to patient selection, operative technique, and early and late outcome. METHODS All patients who had IVC replacement for primary (n = 2) or secondary (n = 27) vena cava tumors from April 1990 to May 1999 were reviewed. Tumor location and type, clinical presentation, the segment of IVC replaced, graft patency, performance status of the patient, and tumor recurrence and survival data were collected. Late follow-up data were available for all but one patient. The IVC was replaced in 28 patients with large diameter (> or =14 mm) externally supported ePTFE grafts and with a panel graft of superficial femoral vein in the other. Three patients had a femoral arteriovenous fistula. Graft patency was determined before hospital dismissal and in follow-up by vena cavography, computed tomography, ultrasonography, or magnetic resonance imaging. RESULTS There were 18 women and 11 men, with a mean age of 53.1 years (range, 16-88 years). Over one half of patients had symptoms from their tumor. IVC replacement was at the suprarenal segment in 15 patients, of whom 13 had concomitant major hepatic resection, at the infrarenal segment in 10, at both caval segments in three, and at the renal vein confluence in one. There were two early deaths (6.9%). One patient died intraoperatively of coagulopathy during liver resection and suprarenal IVC replacement. The other death occurred 4 months postoperatively, from multisystem organ failure that resulted in graft infection and occlusion. Twelve patients had one or more major complications- cardiopulmonary problems in five; bleeding in five; chylous ascites or large pleural effusions in two patients each; and lower extremity edema with tibial vein thrombosis in one. The mean follow-up was 2.8 years (range, 2.7 months to 6.3 years). Two late graft occlusions occurred: one at 7.5 months, the other, from tumor recurrence, at 6.3 years. There have been no other late graft-related complications. All 11 late deaths were caused by the progression of malignant disease. Of 16 survivors, 12 have no evidence of disease and four have either regional or distant metastatic recurrence. Initial postoperative performance status was good or excellent for most survivors. CONCLUSIONS Aggressive surgical management may offer the only chance for cure or palliation of symptoms for patients with primary or secondary IVC tumors. Our experience suggests that vena cava replacement may be performed safely with low graft-related morbidity and good patency in carefully selected patients.

Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature

INTRODUCTION Splenic artery pseudoaneurysm is uncommon. We report our institutions recent 18-year experience with these aneurysms and review the literature. METHODS We reviewed the records for 37 patients with visceral artery pseudoaneurysm evaluated at our institution from 1980 to 1998. From this group we found only 10 patients (27%) with splenic artery pseudoaneurysm. We also reviewed 147 cases of splenic artery pseudoaneurysm reported in the English literature. RESULTS In this series of 10 patients, 5 were men. Mean age was 51.2 years (range, 35-78 years). Causes of aneurysm included chronic pancreatitis in 4 patients, trauma in 2 patients, iatrogenic cause in 1 patient, and unknown cause in 3. The most common symptom was bleeding in 7 patients and abdominal or flank pain in 5 patients; 2 patients had no symptoms. Aneurysm diameter was known for four pseudoaneurysms, and ranged from 0.3 to 3 cm (mean, 1.7 cm). Splenectomy and distal pancreatectomy were performed in 4 patients, splenectomy alone in 2 patients, endovascular transcatheter embolization in 2 patients, and simple ligation in 1 patient. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. Follow-up data were available for 7 patients, with a mean of 46.3 months (range, 4.5-120 months). CONCLUSIONS Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.

Ruptured abdominal aortic aneurysms: Repair should not be denied

The records of 231 patients (189 men, 42 women) treated during the last decade for ruptured infrarenal abdominal aortic aneurysm were reviewed to evaluate complications and mortality rates and to determine if preoperative factors would preclude attempt at surgical repair. Mean age was 73.7 years (range, 50 to 95 years). Fifty-seven patients (24.7%) were greater than or equal to 80 years of age. Sixty-eight patients (29.4%) had known abdominal aortic aneurysm before rupture. Preoperative systolic blood pressure was less than or equal to 90 mm Hg in 155 patients (67.1%). Fifty-six patients (24.2%) had cardiac arrest before operation. The overall mortality rate from admission until the end of the hospital stay was 49.4% (114 of 231). Seventeen patients (7.4%) died in the emergency department, 40 (17.3%) in the operating room, 27 (11.7%) during the first 48 postoperative hours, and 30 (13.0%) died later but during the same hospitalization. The 30-day operative mortality rate was 41.6%. Mean age of those who died was higher (75.3 years) than of those who survived (72.2 years) (p less than 0.02). Of patients greater than or equal to 80 years, 43.9% survived. Survival was lower among women (35.7%) than men (54.0%; p less than 0.04). A high APACHE II score, a low initial hematocrit, preoperative hypotension, and chronic obstructive pulmonary disease were associated multivariately with increased mortality rates (p less than 0.02). However, 59 of the 155 patients (38.1%) with preoperative hypotension survived. Deaths were high (80.4%) among patients with cardiac arrest (45 of 56); still, 28.2% of patients (11 of 39) survived repair after cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Reconstruction of large veins for nonmalignant venous occlusive disease

To evaluate the effectiveness of venous grafting, we reviewed the management and clinical course of 28 patients (21 males and seven females) who underwent 29 reconstructions of large veins for benign disease. There were 12 patients with superior vena cava (SVC) syndrome, two with subclavian vein thrombosis, and 15 with occlusion of the inferior vena cava (IVC) or iliac veins. One of these patients underwent both IVC and SVC reconstructions. Reconstruction of the SVC was performed with spiral saphenous vein graft (SSVG) in nine patients and expanded polytetrafluoroethylene (ePTFE) in three. All seven straight SSVGs had documented patency at a median of 7 months (2 weeks to 5 years) after reconstruction. Six patients had complete relief of symptoms. Two patients with bifurcated SSVG had early occlusion of one graft limb. Two of the three ePTFE grafts needed early thrombectomy. One graft reoccluded at 6 months and two were patent at 2 and 5 years. The two subclavian vein reconstructions with axillary-jugular ePTFE grafts with an arteriovenous fistula had documented early patency. Both patients had rapid resolution of symptoms. The IVC or iliac vein was reconstructed with ePTFE graft in 11 patients, SSVG in three, and Dacron in one. A femorofemoral arteriovenous fistula was added in eight patients with ePTFE grafts. Seven of the 11 ePTFE grafts had documented patency at the last follow-up (median 9 months; range 2 weeks to 5 years). None of the three SSVGs had documented long-term patency. The one Dacron cavoatrial graft occluded at 3 years. A straight SSVG continues to be our first choice for SVC replacement. Short, large-diameter ePTFE grafts perform the best in the abdomen. Femorocaval or long iliocaval grafts need an arteriovenous fistula to maintain patency. Long-term patency after closure of the fistula is still unknown. Femorocaval grafts with poor venous inflow have limited chance of success. Failed or failing grafts may be salvaged by early thrombectomy. Venous reconstruction to treat selected patients with symptoms with large vein occlusion continues to be a viable option.

The results of in situ prosthetic replacement for infected aortic grafts

BACKGROUND Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.

Benign superior vena cava syndrome: Stenting is now the first line of treatment

BACKGROUND Endovascular repair (EVR) is emerging as first-line treatment for patients with superior vena cava (SVC) syndrome of benign etiology, but data on its durability remain scarce. The aims of this study were to assess the efficacy and durability of EVR and compare results of EVR with open surgical reconstruction (OSR). METHODS Data from 70 consecutive patients undergoing treatment for benign SVC syndrome between November 1983 and November 2006 were retrospectively reviewed. RESULTS There were 30 males and 40 females (mean age, 41 years; range, 5-75 years). Etiology included indwelling catheters or pacemaker wires in 35 patients, mediastinal fibrosis in 31, idiopathic thrombosis in 2, hypercoagulable disorder in 1, and postsurgical thrombosis in 1. In 42 patients, OSR was done through a median sternotomy: repair was with spiral saphenous vein in 22, expanded polytetrafluoroethylene (ePTFE) in 13, femoral vein grafts in 6, and human allograft in 1. Fifteen OSRs followed failed EVR interventions. EVR was attempted in 32 patients and was successful in 28 (88%): 19 had stenting, 14 had percutaneous transluminal balloon angioplasty (PTA), 2 had thrombolytic therapy with PTA, and 3 had stenting. All four technical failures subsequently underwent OSR. There were no early deaths in either group. Periprocedural morbidity was 19% after OSR and 4% in the EVR group. Six early surgical graft failures were successfully treated with surgical revision; one restenosis after EVR was restented. During a mean follow-up of 4.1 years (range, 0.1-17.5 years) after OSR, 11 patients underwent 18 secondary interventions. Mean follow-up after EVR was 2.2 years (range, 0.2-6.4 years), and nine patients underwent 21 secondary EVR interventions. Primary, assisted primary, and secondary patency rates of surgical bypass grafts were, respectively, 45%, 68%, and 75% at 3 and 5 years. Primary, assisted primary and secondary patency rates after EVR were 44%, 96%, and 96% at 3 years. Assisted primary patency was significantly higher in vein grafts than in ePTFE grafts (P = .05). Assisted primary and secondary patency was significantly higher in patients undergoing stenting compared with PTA (P = .02). At last follow-up, 93% of patients in both OSR and EVR groups had significant relief from symptoms. CONCLUSIONS OSR of benign SVC syndrome is effective, with durable long-term relief from symptoms. EVR is less invasive but equally effective in the mid-term, albeit at the cost of multiple secondary interventions, and is an appropriate primary treatment for benign SVC syndrome. OSR remains an excellent choice for patients who are not suitable for EVR or in whom the EVR fails.