Citations

Currently available aortic stent-grafts require bilateral femoral incisions for device deployment. The incidence of morbidity (infection, lymphatic complications, breakdown) of vertical, infrainguinal incisions used in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) was assessed, and the natural history of asymptomatic groin fluid collections following such procedures was determined. Between June 1999 and February 2001, 77 consecutive patients underwent EVAR for AAAs utilizing bilateral vertical femoral incisions. Fifty-nine (77%) bifurcated stent-grafts (BSGs), and 18 (23%) aortouniiliac (AUI) devices, with femorofemoral bypass were performed. Patients returned at 2 weeks, 1 month, and 6 months for physical examination, and 1 month and 6 months for abdominal and pelvic computed tomography (CT) scans. The presence of fluid collections was determined from the dictation report of the attending radiologist. Data are reported as (n) mean ± SE. Patient characteristics were compared using Fisher's exact test; p <0.05 considered significant. There were 72 males and 5 females, age 75 ±6.4 years and aneurysm size (77) 5.6 ±0.8 cm. There were no cases of wound breakdown or lymph fistula. Wound infections occurred in 3/150 incisions (2%), 2/34 AUI incisions (6%), and 1/1 16 BSG incisions (0.86%). There was no statistical difference (p =0.13) between graft types (BSG vs AUI). All infections were diagnosed clinically before the 1-month CT scan, treated without operative intervention or hospitalization, and resolved. There was a significant decrease in the BSG group and overall in asymptomatic wound fluid collections from 1 to 6 months postoperatively. At 1 and 6 months, respectively, the BSG group had 17 (14.6%) and 3 (2.6%) fluid collections out of 116 incisions (p = 0.003); the AUI group had 6 (17.6%) and 1 (2.9%) fluid collection(s) out of 34 incisions (p = 0. 13); and overall 23 (15.3%) and 4 (2.6%) out of 150 incisions (p = 0.004). The present study demonstrates that bilateral vertical femoral incisions used in EVAR have a wound infection rate of 2.0%. Infections are usually detected and treated clinically and empirically without the need for hospitalization or surgery. Asymptomatic groin wound fluid collections resolve significantly within 6 months without intervention. Therefore, surgical femoral artery exposure adds little morbidity to the endovascular repair of abdominal aortic aneurysms.

Vascular events that occur in the brain also occur in the eye, giving rise to different ophthalmologic manifestations that range from amaurosis fugax to complete blindness due to central retinal artery occlusion. The objective of this study was to ascertain the relative frequency and predictive value of ocular findings suggestive of carotid occlusive disease in patients being investigated for carotid endarterectomy. The charts of 366 patients undergoing carotid angiography for evaluation of cerebrovascular or visual symptoms over a 5-year period were reviewed. The presence of eye symptoms, neurologic symptoms, cervical bruits, and ophthalmologic findings on admission was recorded and correlated with the presence of significant carotid artery stenosis (? 50%). Positive eye findings included retinal plaques, rubeosis iridis, neovascular glaucoma, venous stasis retinopathy, central and branch retinal artery occlusion, ischemic optic neuropathy, and asymmetric hypertensive retinopathy. Seventy-five patients (21%) presented with amaurosis fugax; 41 patients (11%) were found to have one or more ocular findings consistent with carotid artery disease. All patients with positive eye findings were diagnosed by ophthalmologists, who were consulted in 94 cases. Of these 41 patients, 29 (70.3%) were subsequently shown to have greater than 50% stenosis of the common or internal carotid artery. Ten patients had amaurosis fugax, a carotid bruit, and positive eye findings. All were shown to have a significant carotid stenosis. This study shows that ocular pathology, if diagnosed, is correlated with carotid stenosis, especially if other contributing history and physical findings are also considered.

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with postthrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p=0.001), and median outcome score was +2 (mean 1.9; range, -I to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.

In situ lesser saphenous vein (LSV) graft has been advocated in cases where the greater saphenous vein is not available and the target arteries are confined to the lower leg. This is often the case of diabetic patients, whose occlusive disease pattern typically affects the tibioperoneal vessels, sparing the femoropopliteal segment. The in situ technique offers the potential advantages of decreasing surgical trauma to the vein and its vasa vasorum, better size-matching between vein and artery at the anastomoses, and improving hemodynamics. The authors reviewed the use of in situ LSV graft with attention to its indications and technical requirements. A 73-and a 76-year-old man presented with critical limb ischemia. Both had a history of diabetes, chronic renal failure, and previous use of the greater saphenous veins for coronary or peripheral bypasses. Both had good femoropopliteal inflow and tibioperoneal disease with single runoff through the distal peroneal and common plantar arteries, respectively. Venous mapping showed diminutive veins, with exception of an adequate ipsilateral lesser saphenous vein. The patients were placed in prone position for a posterior approach. The lesser saphenous veins were exposed through a longitudinal incision. Proximal anastomosis was based on the popliteal artery, exposed through the same incision. A successful in situ lesser saphenous vein bypass was performed by using the common plantar and the distal peroneal artery as target vessels. Both bypasses were patent at 24 and 18-months' follow-up, respectively. Selection criteria for in situ LSV bypass are patent femoral arteries; accessible target vessels in prone position through a medial, posterior, or lateral approach; and adequate LSV in diameter and length. In the authors' experience, in situ LSV bypass is a safe and simple option that offers successful distal revascularization.

The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1,1990. and January 1,1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients ( 2 %) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.

Carotid-carotid bypass grafting is a procedure only rarely performed. However, in selected cases it may provide an excellent treatment alternative. The authors report on two patients who were treated by carotid-carotid bypass. The first patient had recurrent cerebral emboli from a chronic aortic dissection extending into the right innominate, common carotid, and internal carotid artery. The second patient was symptomatic from a recurrent high-grade internal carotid artery stenosis and an ulcerated plaque in the right common carotid artery following radical neck dissection and radiotherapy. The indications for this procedure are described and the related literature is reviewed.

Ureteral obstructions following aortoiliac or aortofemoral bypass grafting for aortoiliac occlusive and aneurysmal disease are infrequently reported. Ureteral obstructions can be self-limiting and resolve without further treatment or can signify a more serious underlying complication such as graft infection or a pseudoaneurysm formation. The authors present a series of five patients with ureteral obstruction secondary to aortobifemoral bypass grafting. Different treatment options are described and an algorithm for the management of these complications is presented.

Genomics is the study of the structure and function of the human genome including genes and their surrounding DNA sequences. The over 3 billion base pairs of the human genome have now been sequenced and approximately 25 000 genes acknowledged. However, only 1% of the entire genome has been assigned to protein coding and decades more work is anticipated to define the functional relevance of noncoding DNA as well as the basis and consequences of sequence variations among individuals. For medical scientists, the focus remains on discovering both disease-causing and disease-susceptibility genes. For pharmaceutical companies, the opportunity to develop molecularly targeted therapy is not going unnoticed. For the practicing physician, the prospect of genomic medicine that incorporates molecular diagnosis and pathogenesis-targeted therapy requires basic understanding of terminology and concepts in molecular biology and the corresponding laboratory tests.