William E. Lloyd

Carotid endarterectomy by eversion technique: its safety and durability.

SUMMARY BACKGROUND DATA The outcome of standard longitudinal carotid endarterectomy (CEA) can be measured by preservation of neurologic function with a low incidence of restenosis. Closure of the internal carotid arteriotomy with or without a patch may predispose to restenosis. Alternatively, transection of the internal carotid artery at the bulb with eversion endarterectomy allows expeditious removal of the plaque and direct visualization of the endpoint. Because the proximal internal carotid artery is anastomosed to the common carotid artery, this obviates the need for patch closure. The authors report their results with this technique in more than 2200 procedures. METHODS From May 1993 to March 1998, 1855 patients underwent 2249 CEAs using the eversion technique. During the same period, 410 patients had 474 CEAs by standard technique. Three hundred fifteen procedures in the eversion group and 65 procedures in the standard group were combined CEA and coronary artery bypass grafts. Most solo CEAs (97%) were performed in awake patients using regional anesthesia. Shunts were used on demand in 6% of CEAs. RESULTS The operative mortality rate was 1.02% (16/1575) in the solo eversion group and 2.2% (9/410) in the standard group. There were 18 permanent neurologic deficits (0.8%) in the eversion group and 11 (2.3%) in the standard group. Transient neurologic deficits occurred in 20 patients (0.9%) in the eversion group and 13 patients (2.7%) in the standard group. Of the 1855 patients, 1786 (96%) presented for duplex ultrasound follow-up. There were seven (0.3%) stenoses greater than 60% in the eversion group versus five (1.1%) in the standard group. CONCLUSIONS Eversion CEA can be performed safely with a low rate of stroke and death and a minimal restenosis rate in short- and long-term follow-up.

Fate of the excluded abdominal aortic aneurysm sac: Long-term follow-up of 831 patients

PURPOSE Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed. METHODS From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed. RESULTS The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 +/- 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted. CONCLUSION Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention.

The incidence, natural history, and outcome of secondary intervention for persistent collateral flow in the excluded abdominal aortic aneurysm

OBJECTIVE The goal of abdominal aortic aneurysm (AAA) repair is the prevention of rupture. Exclusion of the infrarenal AAA by means of operation or endovascular graft placement is an alternative therapy to achieve this goal. However, thrombosis of the excluded aneurysm sac does not always occur and further intervention may be needed. This study examines the efficacy of available screening methods to detect the persistence of aneurysm sac flow and the outcome of secondary procedures to treat this problem. METHODS During the past 14 years, 1218 patients have undergone operative retroperitoneal exclusion of AAA. To date, 48 patients have been found to have persistent flow in the excluded AAA sac with duplex scanning. Twenty-seven patients underwent surgical intervention, and seven of these procedures were performed for rupture. Six patients have undergone treatment with interventional techniques (four successfully). The patients were evaluated for preoperative angiographic, anatomic, and comorbid factors that may have predisposed them to failed exclusion. Also, perioperative morbidity and mortality, estimated blood loss, and survival were assessed in the patients who required surgical treatment. RESULTS There were no perioperative parameters that correlated with postoperative persistent flow in the excluded AAA sac. The mean time to secondary intervention was 51 months (range, 2 to 113 months). Two patients had false-negative computed tomographic angiogram results, eight patients had false-negative angiogram results, and six patients had duplex scan examinations that had initially negative results that were then positive for flow in sac. Reoperation had a 7.4% mortality rate (two deaths) and a median blood loss of 2600 mL, as compared with 500 mL for primary procedures. CONCLUSION Secondary operations for patent excluded aortic aneurysm sacs have higher mortality and intraoperative blood loss rates than do primary procedures for AAA repair. The localization of branch leaks with computerized tomographic angiography, angiography, and duplex scanning were imprecise, and better methods are needed to adequately diagnose patent sacs. Expansion of AAA sac may be the only reliable factor.

Infrainguinal arterial reconstruction for claudication: Is it worth the risk? An analysis of 409 procedures☆☆☆

PURPOSE Infrainguinal reconstruction traditionally has been reserved for patients with limb-threatening ischemia. Surgery for debilitating claudication, however, has been discouraged as a result of the perceived fear of bypass graft failure, limb loss, and significant perioperative complications that may be worse than the natural history of the disease. In this study, the results of infrainguinal reconstructions for claudication performed during the past 10 years were evaluated for bypass graft patency, limb loss, and long-term survival rates. METHODS Data were collected and reviewed from the vascular registry, the office charts, and the hospital records for patients who underwent infrainguinal bypass grafting for claudication. RESULTS From 1987 to 1997, 409 infrainguinal reconstructions were performed for claudication (9% of all infrainguinal reconstructions in our unit). The patient population had the following demographics: 73% men, 28% with diabetes, 54% smokers, and an average age of 64 years (range, 24 to 91 years). Inflow was from the following arteries: iliac artery/graft, 10%; common femoral artery, 52%; superficial femoral artery, 19%; profunda femoris artery, 16%; and popliteal artery, 2%. The outflow vessels were the following arteries: 165 above-knee popliteal arteries (40%), 150 below-knee popliteal arteries (37%), and 94 tibial vessels (23%). The operative mortality rate was 0%, and one limb was lost in the series from distal embolization. The primary patency rates were 62%, 77%, and 86% for above-knee popliteal artery, below-knee popliteal artery, and tibial vessel reconstructions at 4 years, and the secondary patency rates were 64%, 81%, and 90%, respectively. Cumulative patient survival rates were 93% and 80% at 4 and 6 years as compared with 65% and 52%, respectively, for infrainguinal reconstructions performed for limb salvage. CONCLUSION Infrainguinal arterial reconstruction for disabling claudication is a safe and durable procedure in selected patients. These data indicate that concern for limb loss, death, and limited life span of the patients with this disease may not be warranted.

Aortic replacement for abdominal aortic aneurysm in elderly patients

Improvements in the operative mortality and morbidity rates in elective aortic replacement, which are largely a result of refinements in surgical technique and perioperative management, have allowed a more aggressive approach in the treatment of abdominal aortic aneurysm (AAA) in elderly patients. To evaluate this approach, we reviewed the records of 116 patients 80 years of age and older (range: 80 to 93 years) who consecutively underwent aortic replacement for AAA. Seventy-seven patients underwent elective aortic replacement with 8 complications and a 3% operative mortality rate (2 of 77). Emergent aortic replacement was performed in 39 patients (14 with symptomatic nonruptured AAA and 25 with ruptured AAA) with 12 complications. In this nonselective subset, there were eight deaths, for an operative mortality rate of 20% (symptomatic 14%, ruptured 24%). In comparison, 780 patients less than 80 years of age underwent aortic replacement during the same time period. Within this group, 622 patients who were treated on an elective basis had a similar operative mortality (2%) as did patients 80 years of age and older. On the basis of these results, we believe that elective aortic replacement in elderly patients is justified and can be achieved with low operative mortality and morbidity rates. We suggest that the chronologic age of the patient should not deter aortic replacement.

Advances in the surgical repair of ruptured abdominal aortic aneurysms

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (< 5%). However, surgical results of ruptured abdominal aortic aneurysms have remained fairly constant with about 50% in hospital mortality rates. Growing experience with the use of the left retroperitoneal exposure for elective aortic surgery allowed the authors to extend the use of this technique to the repair of ruptured abdominal aortic aneurysm. The extended left retroperitoneal approach using a posterolateral exposure through the 10th intercostal space allowed the surgeon expeditiously and reliably to obtain supraceliac aortic control by dividing the left crus of the diaphragm in all patients. In total, 104 aortic replacements were performed for ruptured abdominal aortic aneurysm during the past 7 years. Of these patients, 87 were men and 17 women; mean(range) age was 72(52-95) years. Hemodynamic instability (as defined by a systolic blood pressure of < 90 mmHg) was present before surgery in 41% (43/104) of patients. The operative mortality rate was 27.9% (29/104). Preoperative hemodynamic instability, time of operative delay and aortic cross-clamp time did not correlate with operative mortality. The median duration of intensive care unit stay was 4 (range 1-60) days and hospital stay 11 (range 6-175) days. The results of this series identified that a change in the operative technique for the repair of ruptured abdominal aortic aneurysm beneficially affected patient survival. The authors suggest that expeditious supraceliac control without thoracotomy is an excellent alternative and offers an advantage in the surgical management of ruptured abdominal aortic aneurysm.

Repair of large abdominal aortic aneurysm should be performed early after coronary artery bypass surgery.

PURPOSE The surgical repair (coronary artery bypass grafting [CABG]) of symptomatic coronary artery disease (CAD) in patients with co-existent large abdominal aortic aneurysm (AAA) may result in an increased rate of AAA rupture after operation. Simultaneous CABG/AAA repair has been recommended by some surgeons, but with a somewhat higher mortality rate than staged repair. We reviewed the outcome of staged AAA repair that was performed early after CABG in patients with symptomatic coronary disease and AAA. METHODS The records of all the patients with symptomatic CAD that required CABG with large AAA (greater than 5 cm) were reviewed. In most patients, CABG was performed first, followed by AAA repair within 2 weeks. Patient demographics, severity of coronary disease, AAA size, interprocedure duration, and perioperative morbidity and mortality rates were examined. RESULTS Between 1991 and 1998, 1105 AAA repairs were performed. Within this group, 30 patients with AAA underwent CABG for symptomatic CAD. Mean AAA size was 6.6 cm (range, 5.0-10.0 cm). The median interprocedure interval between CABG and AAA repair was 11.5 days. There was no in-hospital AAA rupture during this interval. The patient group was comprised of 24 men and 6 women with a mean age of 71 years. There was no operative death after such staged AAA repair, and nonfatal complications occurred in seven patients (23%). During this period, seven patients had AAA rupture when they were sent home after CABG for recovery and intended AAA repair at a later date. CONCLUSION Staged elective AAA repair may be performed safely and effectively after CABG. Performance of these procedures with a short interprocedure interval may be preferable to the higher complication rate observed after combined procedures.

Expeditious management of ischemic invasive foot infections.

Management of infected ischemic diabetic limbs requires antibiotic therapy, abscess drainage, and revascularization. However, revascularization is often delayed for several days or weeks as the infection is controlled. In an effort to decrease hospital stay and costs and to increase limb salvage, a series of 974 extremities with distal occlusive disease were managed with autogenous distal bypass. Some 136 of these limbs (125 diabetic) had severe invasive infections. These patients received intravenous antibiotics in all cases and abscess drainage if necessary. Vascular reconstruction was carried out as soon as possible, within 48 h of admission. An in situ bypass was used preferentially (107 cases). Patients were maintained on intravenous antibiotics in the perioperative period. Partial foot amputations, when necessary, were performed in 111 cases, usually 3-5 days after vascular reconstruction. There were no graft infections or major wound infections. There were two cases of skin edge necrosis requiring reoperation due to flap mobilization and consequent ischemia. Urgent revascularization with an autogenous conduit may be carried out in patients with invasive foot infections expeditiously, with high rates of limb salvage. Graft and wound infections are not common in this setting. Costly prolonged pre-bypass hospitalization in these cases is unnecessary.

Is the iliac artery a suitable inflow conduit for iliofemoral occlusive disease: An analysis of 514 aortoiliac reconstructions

PURPOSE The aorta is the conventional inflow source for reconstructions in patients with aortoiliofemoral occlusive disease. In patients with unilateral iliac or femoral disease, femoral-to-femoral bypasses have been used but with less favorable patency rates. The purpose of this study is to evaluate the performance of the unobstructed iliac artery as an inflow source for ipsilateral, contralateral, or bilateral reconstructions in iliofemoral occlusive disease. METHODS Over the past 6 years 322 reconstructions have been performed with the iliac artery as the donor vessel. Patients were evaluated for proximal hemodynamically significant lesions by augmented pullout pressures during aortography. Patients who had balloon angioplasty were excluded. RESULTS Results were compared with 192 patients who underwent conventional aortodistal bypass operation for occlusive disease during the same period. Both groups were similar in risk factors, age, sex, and indications for operation. For the iliac group the operative mortality rate was 1.6%, and the 30-day patency rate was 97%, similar to those in the aortic group (3.6% and 95%, respectively). Cumulative patency rates at 5 years by life-table analysis were 82% for iliac artery inflow and 77% for aortic inflow reconstructions. CONCLUSIONS Our experience suggests that an unobstructed iliac artery is a reasonable inflow source for reconstructions in iliofemoral occlusive disease. The long-term patency rate is comparable to aortodistal bypasses and superior to other extraanatomic bypasses.

Origin of deep vein thrombi in an ambulatory population

Eighty symptomatic ambulatory outpatients with acute deep vein thrombosis were evaluated with ascending contrast venography and ultrasonic imaging to determine the origin and distribution of thrombosis and to analyze clinical risk factors. Isolated calf vein thrombosis was present in 42.5 percent of the limbs, combined calf and proximal deep vein thrombosis in 47.5 percent, and isolated proximal thrombosis in 10 percent of the limbs. Discontinuity of thrombus was present in 55 percent, whereas 45 percent exhibited a continuous column of thrombus. The results of this study indicate that in the ambulatory outpatient population, acute deep vein thrombosis begins segmentally in the calf and proximal vessels and frequently coalesces into a continuous column of thrombus over several days. We believe that all cases of acute deep vein thrombosis should be treated and patients with evidence of previous acute deep vein thrombosis should be closely monitored for possible recurrences.