William J. Quinones-Baldrich

Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach

We report an unusual case of type IV Thoracoabdominal Aneurysm (TAA) with Superior Mesenteric Artery (SMA), celiac artery, and bilateral renal artery aneurysms in a patient who underwent an earlier repair of two infrarenal Abdominal Aortic Aneurysm (AAA) ruptures. Because of the presence of the visceral artery aneurysms and the earlier operation through the retroperitoneum, standard surgical treatment via a retroperitoneal approach with an inclusion grafting technique was considered difficult. A combined surgical approach achieving retrograde perfusion of all four visceral vessels and endovascular grafting allowing exclusion of the TAA was accomplished. Complete exclusion of the aneurysm and normal perfusion of the patients viscera was documented by means of follow-up examinations at 3 and 6 months. The repair of a type IV TAA with a Combined Endovascular and Surgical Approach (CESA) allowed us to manage both the aortic and visceral aneurysms without thoracotomy or re-do retroperitoneal exposure and minimized visceral ischemia time. If the durability of this approach is confirmed, it may represent an attractive alternative in patients with aneurysmal involvement of the visceral segment of the aorta.

Abdominal aortic aneurysm: a 6-year comparison of endovascular versus transabdominal repair.

OBJECTIVE To test the hypothesis that endovascular repair of abdominal aortic aneurysm (AAA) will result in a significant reduction in mortality and morbidity rates and cost when compared with open transabdominal repair. SUMMARY BACKGROUND DATA Since the introduction of endovascular repair of AAA this decade, multiple groups have evaluated different endovascular grafts. Despite the excellent results reported initially, there has been a paucity of well-controlled, comparative studies looking at long-term outcome. METHODS From 1992 to 1998, the first 100 consecutive patients undergoing endovascular AAA repair (mean age 74.7, AAA size 5.6 cm) were compared to 100 patients undergoing transabdominal repair (mean age 72.9, AAA size 5.9 cm). All patients undergoing endovascular repair received a device manufactured by Endovascular Technologies, Inc. (Menlo Park, CA) and were prospectively followed with periodic examination, contrast-enhanced computed tomography, and duplex scanning. Of the 200 patients, 198 have been available for long-term follow-up. RESULTS The two groups had similar preoperative risk factors. Surgical time (211 vs. 256 minutes, p < 0.005), blood loss (326 vs. 1010 ml, p < 0.005), and blood replacement (0.4 vs. 1.6 units, p < 0.005) were all decreased in the endovascular group. Median intensive care unit stay (0 vs. 2 days) and hospital stay (2 vs. 7 days) were significantly reduced in the endovascular group. Insignificant trends in lower morbidity rates (myocardial infarction 1 % vs. 5%, respiratory failure 1 % vs. 5%, colon ischemia 0% vs. 2%) were present in patients undergoing endovascular repair. This led to decreased hospital cost and increased hospital profit. The surgical mortality rate (2% vs. 3%) and 5-year survival rate (65% vs. 72%) have been equivalent between the two groups. CONCLUSIONS The surgical mortality rate is low for both groups and not statistically different. Endovascular repair significantly reduces resource utilization (surgical time, blood replacement, intensive care unit and hospital stay) and cost when compared to transabdominal aneurysm repair. Long-term survival is equivalent in patients undergoing AAA repair regardless of technique. Although endovascular repair appears durable for up to 6 years, longer follow-up studies are warranted.

Prosthetic replacement of the inferior vena cava for malignancy

Abstract Purpose: Invasion of the inferior vena cava (IVC) by tumor is generally considered a criterion of unresectability. This study was designed to review the outcomes of a strategy of aggressive resection of the vena cava to achieve complete tumor resection coupled with prosthetic graft placement to re-establish caval flow. Methods: Retrospective review of patients treated at a university referral center. Ten patients (mean age 54; eight females, two males) underwent tumor resection that involved circumferential resection of the IVC and immediate prosthetic replacement with ringed polytetrafluoroethylene (PTFE) grafts ranging in diameter from 12 to 16 mm. Results: Seven patients had replacement of the infrarenal IVC, two of their suprarenal IVC, and one had reconstruction of the IVC bifurcation. Four of the 10 patients received preoperative chemotherapy, and none received radiotherapy. The most common (7/10) pathologic diagnosis was leiomyosarcoma arising from the IVC or retroperitoneum. Additional diagnoses included teratoma (one), renal cell carcinoma (one), and adrenal lymphoma (one). There were no perioperative deaths, and one complication (prolonged ileus) occurred. Mean length of stay was 8.1 days. Anticoagulation was not routinely used intraoperatively or postoperatively. Follow-up (mean duration=19 months) demonstrated that survival was 80% (8/10) and 88% (7/8) of patients were free of venous obstructive symptoms. Conclusion: Resection of the IVC with prosthetic reconstruction allows for complete tumor resection and provides durable relief from symptoms of venous obstruction. (J Vasc Surg 1998;28:75-83.)

Long-term results of infrainguinal revascularization with polytetrafluoroethylene: A ten-year experience☆

Two hundred fifty-eight patients underwent 322 infrainguinal revascularizations with use of polytetrafluoroethylene (PTFE) between 1978 and 1988. The indication was limb salvage in 190 (59%) reconstructions. Two hundred nineteen (68%) were above-knee, and 75 (23%) were below-knee femoropopliteal bypasses. Twenty-eight (8.6%) were femoral-infrapopliteal bypasses, all done for limb salvage. Follow-up ranged from 24 to 144 months (mean, 66 months). The perioperative mortality rate (1 to 30 days) was 3.4% (9 patients), with no significant difference according to indication (2.9% vs 3.7%). Actuarial primary patency at 8 years for the entire series of femoropopliteal bypasses was 53% (above knee 53%; below knee 39%; p less than 0.05), and improved with additional procedures for a secondary patency of 72%. Femoropopliteal bypasses done for severe claudication had an 8-year actuarial primary patency of 63%, compared with 38% for limb salvage (p less than 0.02). Actuarial limb salvage in the latter group at 8 years was 66%. Femoral-infrapopliteal reconstructions with PTFE had a significantly lower primary patency at 3 years (22%, with a 37% limb salvage). Sixty-four percent of the failures for all reconstructions (N = 111) occurred within 12 months, with remarkable stabilization of patency curves beyond that interval. This experience represents the largest reported series of PTFE reconstruction with longest follow-up to date and may serve as a basis for comparison of other conduits. These results suggest an important role for PTFE in femoropopliteal revascularization and a limited role of this prosthetic conduit in femoral-infrapopliteal arterial reconstructions.

Carotid artery repair for radiation-associated atherosclerosis is a safe and durable procedure ☆ ☆☆

OBJECTIVE The development of carotid atherosclerosis after neck irradiation is well documented. There has been concern about the safety and durability of carotid artery repair through a radiated field. The objective of this report is to describe the immediate and long-term results of a series of cases collected in a 13-year interval. METHODS From 1984 to 1997, 24 patients underwent 26 carotid artery operations. All the patients had undergone prior radiation therapy at a mean interval of 17 years, with an average radiation dose of 6300 rad. Severe scarring of the skin or radiation fibrosis were present in two thirds of the patients, with 4 patients having permanent tracheostomies. The indications for carotid surgery included cerebral or monocular transient ischemic attack (58%), asymptomatic high-grade stenosis (27%), prior stroke (12%), and tumor invasion of the carotid artery (4%). General anesthesia was used with selective shunting on the basis of carotid artery back pressure or electroencephalography monitoring. Patch angioplasty closure was used in 79% of the patients. The operations included standard carotid endarterectomy (n = 20), external carotid endarterectomy (n = 2), carotid patch angioplasty alone (n = 2), aortocarotid bypass grafting (n = 1), and carotid interposition grafting (n = 1). Four patients required skin grafting or myocutaneous flaps. RESULTS No deaths or strokes occurred within 30 days of the operations. Six patients had transient cranial nerve palsy, and two had wound infections. The patients were followed from 1 to 156 months, with six patients being followed for longer than 18 months. No strokes were seen at late follow-up examination. Duplex scan examination documented one occlusion, in a patient with primary closure, and two restenoses, one of which necessitated reoperation. The remainder of the grafts were widely patent. CONCLUSIONS Carotid surgery after neck irradiation is safe and durable. The long-term patency rates and the protection against subsequent neurologic events are similar to the results obtained in the absence of radiation therapy. Problems of wound healing were not found in this series.

The superiority of synthetic arterial grafts over autologous veins in carotid-subclavian bypass

From May 1964 to June 1983, 36 carotid-subclavian bypasses were done in 36 patients who had symptomatic lesions at the origin of the common carotid and/or subclavian arteries at the Center for Health Sciences of the University of California, Los Angeles. Ages ranged from 28 to 82 years (mean, 58 years). Eighteen bypasses were done with prosthetic grafts, 13 done with autogenous vein, and five were transpositions with primary anastomosis of the subclavian and carotid arteries. Follow-up was available on all patients and ranged from 9 to 156 months (mean, 51.5 months). The graft patency rate at 5 years determined by actuarial methods and documented by clinical examination, noninvasive evaluation, and/or arteriography was 94.1% for prosthetic grafts and 58.3% for vein grafts (p less than 0.01). The 5-year cerebrovascular accident (CVA) rate for patients with carotid-subclavian bypass done with prosthetic grafts was 6% in contrast to 39% for those with vein grafts (p less than 0.0545). All reconstructions done by transposition and primary anastomosis remain patent and there have been no late CVAs. We conclude that prosthetic grafts are the arterial substitute of choice in carotid-subclavian bypass. Transposition and primary anastomosis between the carotid and subclavian artery, when technically feasible, may be preferable to the use of free grafts in carotid-subclavian reconstruction.

Is the preferential use of polytetrafluoroethylene grafts for femoropopliteal bypass justified

The objective of this review is to analyze the long-term results of femoropopliteal bypass done preferentially with polytetrafluoroethylene (PTFE) grafts in patients who presumably had saphenous vein available. The results are analyzed according to preoperative variables in an attempt to determine those instances in which PTFE grafts may be preferred for the first reconstruction and to identify those patients who benefited from vein preservation. From 1979 to 1985, 146 femoropopliteal bypass operations were performed in 120 patients with 6 mm PTFE grafts used preferentially. The results with follow-up at 5 years are analyzed by actuarial methods. The patency rate at hospital discharge was 100%. The overall primary patency rate at 5 years was 57%. Reconstructions above the knee (101) and below the knee (45) had significantly different 5-year patency rates (63% vs 44%, p less than 0.03). Sixty-two reconstructions done to alleviate disabling claudication had a 5-year primary patency rate of 69% and no amputations. Eighty-one reconstructions were done to treat critical ischemia with a 5-year patency rate of 49% and a 5-year foot salvage rate of 73%. When secondary operations were required to treat graft failures, the 4-year cumulative patency rate of the secondary reconstruction was 18% when performed with a prosthetic graft, in contrast to 70% when performed with the spared saphenous vein. We conclude that femoropopliteal reconstruction with PTFE grafts is a reasonable alternative for older patients with disabling claudication. Patients with critical ischemia will likely benefit from preservation of the vein with initial femoropopliteal reconstruction done with PTFE. Staged infrainguinal revascularization for foot salvage may improve present results. In this regard the sequence PTFE-then-vein carries a higher predicted patency rate than the sequence vein-then-PTFE.

Effect of a prior portasystemic shunt on subsequent liver transplantation.

Fifteen patients who had a prior portasystemic shunt underwent orthotopic liver transplantation. Shunt types were portacaval in six patients, H-graft mesocaval in six, distal splenorenal in two, and proximal splenorenal in one. Mean blood loss and hospital stay were highest in the portacaval group. Retransplants (two patients) and deaths (two patients) also were limited to this group. In this report, technical considerations, advantages, and disadvantages of the various shunt types are described. Management of patients with late stages of portal hypertension must include estimation of the effects of a portasystemic shunt on subsequent liver transplantation. It is concluded that portacaval shunts should be avoided in patients who may be considered for transplantation. Distal splenorenal shunts are best performed in younger patients with intractable variceal bleeding who are not expected to require transplantation in the near future. A mesocaval H-graft is the shunt of choice in patients who are current liver transplant candidates.

Can clinical evaluation and noninvasive testing substitute for arteriography in the evaluation of carotid artery disease

The objective of this study was to prospectively assess the value of combining clinical assessment and noninvasive testing in predicting the spectrum of carotid bifurcation pathology, as subsequently proven by arteriography, in order to determine the safety and accuracy of performing carotid endarterectomy without angiography. A panel of eight specialists representing vascular surgery, neurology, and neurosurgery were presented with the history, physical findings, and noninvasive test results (GEE-OPG and duplex scan) of 85 patients. They were asked to make an anatomic prediction of the status of each carotid artery (170 arteries) as to whether the bifurcation was normal, ulcerated, had a hemodynamically significant stenosis, or was occluded. The predictions were then prospectively evaluated and correlated with angiographic findings; 159 of 170 (93.5%) carotid arteries were accurately characterized; 73 of 80 (91%) symptomatic carotid arteries and 86 of 90 (95.5%) asymptomatic arteries were correctly characterized; 61 of 61 (100%) stenoses of hemodynamic significance, nine of 14 (64.3%) ulcerations without stenosis, and 18 of 18 (100%) of total occlusions were accurately identified by the panel. Twenty-nine patients have subsequently had 32 carotid endarterectomies without angiography, and the predicted lesion was confirmed at the time of exploration. The combination of clinical assessment and noninvasive testing, particularly duplex scanning, when performed in a laboratory with validated accuracy may with defined qualification be safely used as a substitute for contrast angiography.

Carotid-Subclavian Bypass for Brachiocephalic Occlusive Disease: Choice of Conduit and Long-term Follow-up

BACKGROUND AND PURPOSE Atherosclerotic disease of the proximal brachiocephalic circulation may produce disabling symptoms referable to cerebral or upper extremity hypoperfusion and embolization. Bypass of occlusive lesions can provide durable relief of symptoms with minimal complications. The ideal conduit for carotid-to-subclavian and subclavian-to-carotid bypass remains controversial, and it is not clear whether the outflow vessel influences patency and survival. METHODS We performed a retrospective analysis of 60 consecutive carotid-to-subclavian and subclavian-to-carotid bypass procedures. Occlusive lesions were documented preoperatively by arteriography. Patency was determined during follow-up by ultrasound or duplex examination. Actuarial patency, symptom-free survival, and overall survival rates were calculated by the life-table method and analyzed by log-rank test. RESULTS Arterial transposition demonstrated the highest long-term patency rate (100.0 +/- 0.0%). Polytetrafluoroethylene grafts demonstrated the highest bypass graft patency rate (95.2 +/- 4.6%), followed by Dacron grafts (83.9 +/- 10.5%) and saphenous vein grafts (64.8 +/- 16.5%). Symptom-free survival paralleled patency rates, but these differences did not achieve statistical significance. While there were no differences in patency or symptom-free survival by outflow vessel, the overall survival of patients with common carotid lesions was significantly lower than that of patients with subclavian lesions (62.7 +/- 12.8% versus 100.0 +/- 0.0%; P < .05). CONCLUSIONS The outflow vessel does not affect long-term patency in carotid and subclavian bypass procedures; however, patients with common carotid disease demonstrate significantly poorer long-term survival. Transposition results in superior long-term patency, with a trend toward lower results for synthetic grafts and relatively poor results for autogenous vein grafts.