Ultrasmall superparamagnetic iron oxide particles (AMI 227) as a blood pool contrast agent for MR angiography: experimental study in rabbits

We report a case of successful surgical management of a potentially life-threatening complication of aortoiliac stent placement. A 59-year-old man who had Leriche syndrome underwent bilateral iliac artery and infrarenal aortic stent placement at another institution. His history was significant for retroperitoneal lymph node dissection at 19 years of age for testicular cancer. One week after stent placement, the patient was readmitted with abdominal pain, poor oral intake, and diffuse intermittent tenderness. Evaluation with computed tomographic scanning and endoscopy was unremarkable, and the patient was discharged. He was admitted to our institution 1 week later with persistent abdominal pain. A computed tomographic scan of the abdomen revealed a large pseudoaneurysm of the abdominal aorta. The patient underwent urgent exploration, and exclusion of his infrarenal aorta was achieved with aortobifemoral bypass grafting. After the operation, the patient's course was complicated by a large paraduodenal hematoma, which resulted in a gastric outlet obstruction, which was managed without operation. This case illustrates a potential life-threatening complication of extensive stent placement for aortoiliac occlusive disease. Injury to the abdominal aorta must be considered in a symptomatic patient after the placement of stents in the aortoiliac region, beyond the immediate periprocedural period.     

Intraoperative endovascular angioplasty and stenting of iliac artery: an adjunct to femoro-popliteal bypass

BACKGROUND: With the rapid development of endovascular techniques, the management strategy of patients with multilevel atherosclerotic arterial occlusive disease is also evolving. Iliac artery stenting is a means whereby multiple bypass operations can be avoided in such patients. The early results of preoperative iliac artery stenting seem promising but the role of intraoperative iliac artery angioplasty and stenting is less clear. STUDY DESIGN: This study was undertaken to evaluate our early results of a combined endovascular and operative approach to patients with multilevel atherosclerotic arterial occlusive disease. Between June 1995 and March 1997, primary intraoperative iliac artery balloon angioplasty and stent placement were performed on 13 affected limbs of 12 patients undergoing an infrainguinal bypass operation. Indications for operation, patient demographics, and risk factors were noted. The outcome of surgery and the patency rates of bypass graft and stent were also recorded. RESULTS: The initial technical success of primary iliac artery angioplasty and stenting was 93%. An improvement of the ankle-brachial index by a mean value of 0.38 was attained after operation (p < 0.001). Clinical success, based on the criteria suggested by the Society for Vascular Surgery/International Society for Cardiovascular Surgery, was achieved in all patients. There was no operative or hospital mortality. Postoperative morbidity rate was 8% (n = 1). The cumulative 1-year patency rates of iliac stent and infra-inguinal bypass grafts were 100% and 85%, respectively. The limb loss rate was 7%. CONCLUSIONS: The technique of intraoperative angioplasty and stenting can be easily mastered by an experienced and skilled vascular surgeon, using a portable C-arm fluoroscopic unit, in the operation theater. A combined endovascular and operative approach optimizes the therapeutic option to this selected group of patients.     

Randomised comparison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease. Dutch Iliac Stent Trial Study Group

BACKGROUND: Percutaneous transluminal angioplasty (PTA) is a safe, simple, and successful treatment for intermittent claudication caused by iliac-artery occlusive disease. Primary stent placement has been proposed as more effective than PTA. We compared the technical results and clinical outcomes of two treatment strategies-primary placement of a stent across the stenotic segment of the iliac artery, or primary PTA followed by selective stent placement when haemodynamic results were inadequate. METHODS: We randomly assigned 279 patients with intermittent claudication, recruited from departments of vascular surgery, either to direct stent placement (group I, n=143) or primary angioplasty (group II, n=136), with subsequent stent placement in case of a residual mean pressure gradient greater than 10 mm Hg across the treated site. The main inclusion criterion was intermittent claudication on the basis of iliac-artery stenosis of more than 50%, proven by angiography. All patients had a clinical assessment before intervention and at 3, 12, and 24 months. Clinical success was defined as improvement of at least one clinical category. Secondary endpoints were initial technical results, procedural complications, cumulative patency as assessed by duplex ultrasonography, and quality of life. FINDINGS: In group II, selective stent placement was done in 59 (43%) of the 136 patients. The mean follow-up was 9.3 months (range 3-24). Initial haemodynamic success and complication rates were 119 (81%) of 149 limbs and 6 (4%) of 143 limbs (group I) versus 103 (82%) of 126 limbs and 10 (7%) of 136 limbs (group II), respectively. Clinical success rates at 2 years were 29 (78%) of 37 patients and 26 (77%) of 34 patients in groups I and II, respectively (p=0.6); however, 43% and 35% of the patients, respectively, still had symptoms. Quality of life improved significantly after intervention (p<0.05) but we found no difference between the groups during follow-up. 2-year cumulative patency rates were similar at 71% versus 70% (p=0.2), respectively, as were reintervention rates at 7% versus 4%, respectively (95% CI -2% to 9%). INTERPRETATION: There were no substantial differences in technical results and clinical outcomes of the two treatment strategies both at short-term and long-term follow-up. Since angioplasty followed by selective stent placement is less expensive than direct placement of a stent, the former seems to be the treatment of choice for lifestyle-limiting intermittent claudication caused by iliac artery occlusive disease.     

The force/time relationship of clinically used sensory testing instruments

Aortoiliac occlusive disease is a significant cause of lower extremity ischemic symptoms. Over the past two decades, most patients have been treated with a variety of surgical procedures, including aortofemoral and extra-anatomic bypasses. Most recently, percutaneous balloon angioplasty and stents have been successfully used for the treatment of limited iliac lesions. New endovascular grafts that combine vascular grafts with stents in a device with new characteristics may allow the successful treatment of patients with extensive aortoiliac occlusive disease in a less invasive fashion. In our early experience, the endovascular grafts were constructed with Palmaz balloon-expandable stents and standard polytetrafluoroethylene (PTFE) grafts. The 18-month primary and secondary patency rates were 89% and 100%, respectively, with a limb salvage rate of 94%. Endovascular grafts can be successfully used to treat patients with extensive aortoiliac occlusive disease, with excellent early results. Long-term results and further graft improvements will define their role in the treatment of patients with aortoiliac occlusive disease.     

Age at onset in geriatric bipolar disorder. Effects on clinical presentation and treatment outcomes in an inpatient sample

Incisional complications following infrainguinal vein bypass remain a formidable challenge to the vascular surgeon. A retrospective analysis of 250 infrainguinal vein bypass grafts (214 patients) was undertaken to identify risk factors for the development of incisional complications and determine the impact of incisional complications on outcome. Incisional complications occurred in 47 (19%) of the bypasses. The mean age was 67.8 years and 155 (62%) of the bypasses were performed in men. The patients were divided into two groups based on the presence or absence of an incisional complication. By univariate analysis, the contributing factors for an incisional complication were: veteran hospital status, dialysis dependence, anemia, obesity, leukocytosis, and hypoalbuminemia (p < 0.05). By multivariate analysis, veteran hospital status, female gender, leukocytosis, and prior ipsilateral bypass were independent risk factors for incisional complications (p < 0.05). The increased incidence of incisional complications in the veteran's hospital group was associated with anemia, leukocytosis, decreased lymphocyte count, and increased incidence of tissue loss (p < 0.05). By life-table analysis, incisional complications did not influence primary patency (p = 0.73), secondary patency (p = 0.91), limb salvage (p = 0.69), or survival (p = 0.92). However, a significant suppurative soft-tissue infection ultimately resulted in a high rate of major amputation.     

Long-term results after open and semiclosed thrombendarterectomy for aortoiliac occlusive disease

OBJECTIVES: This study reviews the long-term results of 514 aortoiliac thrombendarterectomies (TEA's). DESIGN: A prospective study in a major university hospital in Switzerland. SUBJECTS: 353 male and 62 female patients with aortoiliac occlusive disease. Operative indications: disabling claudication (n=334), rest pain (n=44), and gangrene (n=37). METHODS: Open and semiclosed TEA's were performed on 167 and 347 limbs, respectively. Follow-up was continuous and complete in 97.1 % of patients over a period of more than 15 years. RESULTS: The overall life-table patency rate at 5, 10, and 15 years postoperatively were 93.4 %, 90.4 %, and 84.2 %, respectively. Fifteen years postoperatively, the patency rate of 92.3 % after open TEA was significantly higher (p<0.04) than after semiclosed TEA (79.5 %). However, similar patency rates of 69.5 % and 69.8 % were observed 20 years postoperatively. Further significant prognostic factors on patency were: anatomic localization (p<0.004), preoperative stage of arterial occlusive disease (p<0.008), and gender (p<0.007). Patient's age did not influence the outcome in terms of patency. Hospital mortality rate was 1.2 %. Early obstruction occurred in 2.2 %, leading to subsequent early amputation of 1.4 % and reoperations in 1.2 %. The long-term actuarial survival rates of the patients were 55 %, 36 %, and 18 % after 10, 15, and 20 years postoperatively. CONCLUSION: Both open and semiclosed TEA give highly satisfactory long term results in aortoiliac occlusive disease with a low morbidity and low mortality.     

Lower-extremity arterial endovascular stenting

Intraluminal arterial stenting for the management of arterial occlusive disease of the lower extremities has evolved over the years. Most stents are used to correct inadequacies of PTA or to correct a PTA complication. These include (1) restenosis within 90 days of PTA, (2) chronic iliac occlusion, (3) acute occlusions during PTA, (4) a significant residual gradient following PTA, (5) dissections longer than the angioplasty site, and (6) a 30% or greater residual stenosis after PTA. Both the Palmaz stent and the Wallstent have performed well in the iliac artery system. Their use in the femoropopliteal system has not been as successful and should be reserved for selected cases. Long-term anticoagulation is generally required for femoropopliteal stent patency. Placement in the lower superficial femoral or popliteal artery is best avoided. Re-angioplasty or additional stenting may be used to prolong patency, although with the risk of a second intervention. Progression of arteriosclerosis is a factor to consider when choosing an endoluminal treatment versus standard bypass.     

Changing patterns in aortoiliac reconstruction: a 7-year audit

A prospective vascular audit was performed in this hospital between 1988 and 1994. There was a substantial increase in the number of vascular reconstructions (78 in 1988; 141 in 1994). Aortobifemoral grafts for occlusive disease comprised 18 per cent of the operations in 1988 and 0.7 per cent in 1994 (95 per cent confidence interval 0.086-0.259). There was a corresponding increase in the number of extra-anatomic grafts (from 3 to 20.6 per cent). There was a threefold increase in the number of percutaneous angioplasties performed for iliac occlusive lesions (14 in 1988; 41 plus 13 iliac stent procedures in 1994). This had no impact on the total rate of surgical intervention for aortoiliac disease, although it probably aided the shift to extra-anatomic reconstruction by dilatation of the donor side. To investigate whether this change is national, rather than local, graft sales figures were obtained from two vascular graft companies; these confirmed a national trend away from aortobifemoral grafting and provide some evidence to support an increase in extra-anatomic bypass grafting.     

Introduction of video endoscopic vascular surgery of the pelvic area

The fact that operative lethality and other typical postoperative complications following surgical treatment of aortoiliac atherosclerotic disease are mainly related to the surgical trauma (derived from the extensive abdominal incision and dissection), but not to the classical arterial reconstruction itself, has led us to develop a videoendoscopic aortoiliacal surgical method which is supposed to diminish the potential postoperative complications. Thus, a new endoscopic instrument set for vascular surgery has been developed in close cooperation with Aesculap AG Tuttlingen, Germany. After evaluating the basic techniques of videoendoscopic patching and end-to-side anastomosis with the newly designed instruments on a training model (n = 50), the feasibility of videoendoscopic vascular surgery on aortoiliacal vessels was tried out on human corpses (n = 8). The positive results of the initial survey have finally encouraged us to conduct our first series of animal studies on piglets (n = 25). The investigation regarding ultrasonically monitored blood flow in the femoral arteries after videoendoscopic aortofemoral bypass grafting and other systemic, hemodynamic parameters showed positive results. No complications were encountered in any of the standardized animal studies. Favorable activity levels were recorded. Meanwhile we have performed 5 extraperitoneal videoendoscopic aortofemoral artery bypasses in patients with aortoiliac occlusive diseases. One patient in whom we had occluded the inferior mesenteric artery died due to an ischaemic colitis. The other patients had an uneventful postoperative course. The videoendoscopic vascular procedures were carried out according to the rules of conventional vascular surgery. Nevertheless, further experimental research and development of endoscopic instruments have yet to be done, to optimize the new surgical method and to clarify the advantages of videoendoscopic vascular surgery.     

Early outcome of in situ femorotibial reconstruction among patients with diabetes alone versus diabetes and end-stage renal failure: analysis of 83 limbs

PURPOSE: Both end-stage renal disease and diabetes have been demonstrated to have a negative effect on the outcome of infrainguinal arterial reconstruction, primarily because of increased perioperative morbidity and wound complications. This study was undertaken to determine whether the combination of these comorbid factors affects the outcome of distal arterial reconstruction. METHODS: Eighty-three distal lower extremity arterial bypasses originating from the femoral artery and terminating at the peroneal, anterior, or posterior tibial artery were performed on 76 patients over a 5-year period at a tertiary care medical center. Autogenous greater saphenous vein was used as the bypass conduit in all instances. Combined inflow and composite vein procedures were excluded. RESULTS: There was one perioperative death, for a mortality rate of 1.2%. The diabetes mellitus (DM) plus end-stage renal disease (DM+ESRD) cohort displayed a significantly lower 1-year primary patency rate compared with the diabetes mellitus cohort, 53% versus 82% (p < 0.02). However, the limb salvage rate for the DM+ESRD and DM cohorts during the same time interval were not significantly different, 63% versus 84% (p < 0.06). The 52% 1-year survival rate for the DM+ESRD cohort was strikingly lower than the 90% 1-year survival rate for the DM cohort (p < 0.002). CONCLUSION: Despite the use of the optimal autogenous conduit, the combination of diabetes and end-stage renal disease can be expected to significantly decrease primary graft patency without affecting limb salvage. The greatest effect of these comorbid factors is on patient survival.     

Preliminary clinical outcome and imaging criterion for endovascular prosthesis development in high-risk patients who have aortoiliac and traumatic arterial lesions

PURPOSE: This report reviews our preliminary experience of prospective treatment of arterial lesions with endoluminal grafts in a Food and Drug Administration (FDA)-approved, investigator-sponsored Investigation Device Exemptions study. The utility and accuracy of various imaging methods, including angiography, cinefluoroscopy, computed tomography (CT), intravascular ultrasonography (IVUS), and duplex scanning, in performing the procedures was also assessed. METHODS: Thirty-one patients were evaluated; 17 patients were treated, including 11 with abdominal aortic aneurysms, one with an aortic occlusive lesion, two with iliac artery aneurysms, and three with traumatic arteriovenous fistulas. Twelve of the 14 patients who had aorta and iliac artery lesions were high-risk. The mean follow-up of patients treated was 9 months (range, 6 to 15 months). RESULTS: Aortoaortic endoluminal interposition procedures were not successful for treating abdominal aortic aneurysms early in the study (n = 3). Aortoiliac endoluminal bypass, contralateral iliac artery occlusion, and femorofemoral bypass procedures were successful in seven of eight subsequent cases (88%), with no incidence of endoleaks at either the proximal or distal fixation sites using the deployment methods described in this report. The 30-day operative mortality rate on follow-up evaluations for patients who underwent aortoiliac procedures was 14% (two of 14). Other major complications included transient renal failure in three patients that required short-term (two to eight times) dialysis, one arterial perforation and one dissection, and one prolonged intubation. No myocardial infarctions or strokes occurred. After major complications or identification of limitations in the study, the protocol was modified with the approval of the FDA to help avoid the recurrence of the same problems. There were no deaths or complications in the trauma cases. CONCLUSIONS: Contrast-enhanced CT (axial images and spiral reconstructions) was the most accurate method to determine candidacy for aortoiliac procedures and to choose the site for deployment of the devices. Angiographic scans were misleading in several patients regarding the critical determinants of patient candidacy and device deployment, particularly regarding the presence of a distal aortic neck. Cinefluoroscopy was used in all patient and was particularly useful for determining the continuity of vascular structures and the anatomy of branch arteries and for enabling precise positioning of stent devices. Determination of fixation sites and assessing dimensional information by cinefluoroscopy and angiography were limited by inaccuracies produced by image magnification, parallax, and uniplanar views. IVUS was used to determine the morphologic features of vascular structures (i.e., calcium, thrombus), to perform real-time observation of the expansion of devices, and to assure firm fixation of balloon-expanded stents before the procedures were completed. Duplex scanning was very helpful in assessing and identifying precisely the location of arteriovenous fistulas before intervention and provided assessment at follow-up intervals. Three-dimensional reconstruction imaging technologies such as spiral CT were particularly helpful for assessing the morphologic features of vascular anatomy before the intervention and at follow-up intervals, whereas 3-D IVUS provided a similar real-time perspective during the procedure.     

Value of segmental limb blood pressures in predicting results of aortofemoral bypass

The efficacy of segmental limb blood pressure measurements, assessed noninvasively by Doppler ultrasound, in predicting the result of aortofemoral reconstruction was evaluated in fifty-two extremities with varying extent of aortoiliac and more distal arterial occlusive disease. Three prognostic correlates were analyzed: (1) preoperative proximal thigh/arm pressure index (TPI); (2) preoperative pressure gradient between adjacent leg segments (proximal thigh, above-knee, below-knee, and ankle), normally less than 30 mm Hg; and (3) early postoperative increase in the ankle/arm pressure index (API). After aortofemoral bypass, forty-one limbs (79 per cent) were asymptomatic or improved and eleven were unimproved. The mean TPI in extremities benefiting from aortofemoral bypass, 0.82 +/- 0.17 (+/-1SD) was significantly less than that of unimproved limbs, 1.01 +/- 0.09 (p less than 0.01). Aortofemoral bypass was beneficial in all twenty limbs with normal leg pressure gradients. Conversely, six of twenty-five legs with one abnormal gradient and five of seven with two abnormal gradients failed to improve. The postoperative increase in API was 0.1 or more in all forty-one improved extremities and was less than 0.1 in all eleven failures. Although eleven of thirty-two limbs (34 per cent) with arteriographic evidence of combined aortoiliac and subinguinal occlusive disease were not improved after proximal bypass, the result of operation could not be predicted from the angiographic pattern or severity of distal disease. Segmental limb blood pressures provide useful predictive indices of the efficacy of aortofemoral bypass and the potential need for more distal reconstruction in multisegmental disease.     

Selection of surgical approaches in the treatment of aortoiliac arterial occlusive disease

31 patients with aortoiliac occlusive disease with or without infrainguinal occlusion was treated with thromboendarterectomies, aortoiliac or aortofemoral arterial bypasses, extra-anatomic bypasses and sequential arterial bypasses in the past 5 years. The results were satisfactory. The surgical mortality was 3.2%, the primary 5-year patent rate was 84.2%, and the secondary 5-year patent rate was 96.5%. We emphasize the value of ABI to indicate arterial reconstruction.     

Focal occlusive disease of the common femoral artery: a report of 20 cases

Occlusive disease localized to the common femoral artery without contiguous involvement of the external iliac and superficial femoral arteries is distinctly uncommon in vascular surgical practice. Twenty patients with focal occlusive disease in 21 common femoral arteries are featured in this report. All except one had severe disabling symptoms: Fontaine classification was stage I in one patient, stage IIb in 13, and stage III in six patients. The probable aetiology, based on clinical features and angiographic observations, was identified as atherosclerosis (nine cases), thromboangiitis obliterans (three) and Takayasu's arteritis (two). Histological features of mucoid vasculopathy, a novel disorder, was seen in one patient while no specific aetiology was evident in five patients. Associated lesions were seen in fourteen patients: aortoiliac in one, femoropopliteal in seven (without any continuity to the common femoral lesion), internal iliac in three and tibial in three. Balloon angioplasty of the common femoral artery lesions was attempted in 14 patients with successful outcome in nine. Three patients (including two with failed balloon angioplasty), underwent thromboendarterectomy and two bypass procedures (iliofemoral, one; femoropopliteal, one). Late reocclusion occurred in one patient each in the angioplasty and surgical groups. There were no procedure-related complications in either group.     

Myocardial infarction as a complication of new interventional devices

Percutaneous transluminal coronary balloon angioplasty has been associated with acute myocardial infarction (MI) as a complication of the procedure. Abrupt closure, distal coronary embolization, intimal dissection, coronary spasm, and acute thrombosis are the principal etiologies. New interventional devices (stent, laser, and atherectomy catheters) have been introduced as alternatives or adjuncts to balloon angioplasty. With use of the New Approaches to Coronary Intervention Registry, the incidence, predictors, and outcome of MI as a complication of using these devices as the primary mode of intervention were studied. There were 3,265 patients from 39 participating centers in the cohort treated with new devices. MI was reported as an in-hospital complication of using new devices in 154 patients (4.7%), including Q-wave MI in 36 patients (1.1%), and non-Q-wave MI in 119 patients (3.6%). MI rates were not significantly different among all patients with devices in the cohort treated with atherectomy (directional, extractional, rotational), laser (AIS, Spectranetics) or the Palmaz-Schatz stent. Multivariate logistic regression showed that post-procedure MI was associated with multivessel disease, high surgical risk, postinfarction angina, and presence of a thrombus prior to the procedure. Prior percutaneous transluminal coronary angioplasty was inversely related to the incidence of MI. When a specific cause of MI could be detected, the main etiologies were: coronary embolus 16.9%, and abrupt closure 27.3%. Other major in-hospital complications were higher in the MI group than the non-MI group: death 7.8% versus 0.8% (p <0.001), and bypass surgery 13.6% versus 1.7% (p <0.001). At 1 year, mortality rates remain higher at 12.9% in the MI group versus 4.9% in the non-MI group (p <0.01). Despite different indications for the use of new devices, they were not predictors for MI with the exception of the rotablator. The incidence of MI (1.1% Q-wave, 3.6% non-Q-wave) was comparable to previously reported rates for balloon angioplasty. The occurrence of MI is associated with an increase in other in-hospital complications and a doubling of 1-year mortality.     

Characterization and specificity of B-cell responses in lupus induced by Mycobacterium bovis in NOD/Lt mice

BACKGROUND: Endoscopic treatment of postoperative benign bile duct strictures (BBDS) is technically challenging, and the long-term outcome after stricture dilation remains poorly defined. METHODS: Forty-eight cases of postoperative BBDS with attempted endoscopic treatment (either transient plastic stenting or definitive metal stent insertion) were reviewed. RESULTS: Endoscopic stricture dilation succeeded in 47 of 48 cases (98%). No procedure-related mortality was observed; 16 (33%) procedure-related or stent-associated complications were observed during treatment. Endoscopic treatment was interrupted in five patients. Stricture relapse occurred in 6 of 6 (100%) and 7 of 36 (19%) patients after metal stent insertion and plastic stent removal, respectively (p < 0.001) (mean follow-up periods 50+/-12 and 44+/-34 months, respectively). After plastic stent removal, stricture relapses were more frequent among patients with strictures related to liver transplantation as opposed to other surgical procedures (p < 0.05); these recurrent strictures were successfully treated by repeated insertion of plastic stents on a temporary basis. At the end of follow-up, all but one patient treated with plastic stents had normal serum alkaline phosphatase values. CONCLUSION: Metal stents proved to be inadequate for treating postoperative BBDS. Temporary insertion of a plastic stent (possibly repeated) provided long-term results equal or superior to those reported for surgical biliary drainage. Repeated insertion of plastic stents was more frequently indicated for strictures related to liver transplantation compared with other surgical procedures.     

Preferred strategies for secondary infrainguinal bypass: lessons learned from 300 consecutive reoperations

PURPOSE: To determine the optimal surgical strategies in reoperative infrainguinal bypass, we reviewed our results in 300 consecutive secondary bypasses in 251 patients operated on between Jan. 1, 1975, and Nov. 1, 1993. METHODS: There were 168 men (67%) and 83 women (33%), with a mean age of 64.8 years and a typical distribution of risk factors including smoking (76.4%), diabetes (33.7%), and coronary artery disease (47.1%). The indications for surgery were limb-threatening ischemia in 83.5% and severe claudication in 16.5% of patients. The majority of conduits (n = 213) were autogenous vein and were composed of a single segment of greater saphenous vein in 121 bypasses (57%) and various alternative veins including composite, arm, and lesser saphenous vein in 92 bypasses (43%). Prosthetic conduits included 69 polytetrafluoroethylene, 16 umbilical vein, and two Dacron grafts. RESULTS: There was one perioperative death (0.3%) and a 25% total morbidity rate including a 1.7% myocardial infarction rate. There was a 28.6% early (< 30 days) graft failure and 10.7% early amputation rate for prosthetic bypass grafts compared with 13.6% early graft failure and 5.6% early amputation rates for vein grafts. Autogenous vein bypasses had higher 5-year secondary patency rates than had prosthetic grafts (51.5% +/- 4.6% vs 27.4% +/- 6.1%, p < 0.001). Results with autogenous vein bypass improved significantly from the 1975 to 1984 to the 1985 to 1993 interval with 5-year secondary patency rates increasing from 38.3% +/- 6.9% to 59.1% +/- 5.8% (p = 0.017) and 5-year limb-salvage rates increasing from 40.4% +/- 7.6% to 72.4% +/- 6.6% (p < 0.001). Vein grafts to the popliteal and tibial outflow levels had equivalent long-term results. Vein grafts completed for claudication demonstrated results superior to those for limb salvage, with a 5-year secondary patency rate of 75.8% +/- 8.1% versus 52.3% +/- 7.9% (p = 0.048). Secondary autogenous vein bypass grafting performed after early primary graft failure (< 3 months) did particularly poorly, with only a 27.2% +/- 7.7% 4-year secondary patency rate. Greater saphenous veins tended to perform better than alternative vein bypasses, with a 5-year secondary patency rate of 68.5% +/- 6.0% compared with 48.3% +/- 10.5% (p = 0.09) and a 5-year limb-salvage rate of 77.8% +/- 7.4% versus 54.2% +/- 11.8% (p = 0.046). CONCLUSIONS: When patients suffer a recurrence of limb-threatening ischemia at the time of infrainguinal graft failure, aggressive attempts at secondary revascularization with autogenous vein are warranted based on the low surgical morbidity and mortality rates and the improved patency and limb salvage rates that are currently attainable.     

Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair

PURPOSE: To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA. METHODS: Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months. RESULTS: Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture. CONCLUSIONS: Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk.     

Early predictors of neurodevelopmental outcome in high risk infants

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine +/- sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty +/- thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demonstrate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.     

Exposure to environmental and mainstream tobacco smoke and risk of spontaneous abortion

The present nationwide, multicenter clinical study was carried out in 26 departments of surgery to define the incidence and attendant mortality of intestinal infarction following abdominal aortic surgery, and to identify patients at risk of it. The data consist of 1752 patients who underwent abdominal aortic reconstruction during 1991-1993 as recorded in the Finnish national vascular registry (FINNVASC). Among the 1752 operations, 27 patients treated at 14 different hospitals had intestinal ischemia, and the complete patient records of all 27 cases were reanalyzed. The incidence of bowel infarction was 1.2%. Among patients operated on for a ruptured aneurysm it was 3.1%, whereas 1.0% of patients with nonruptured aneurysm and 0.6% of those operated on for aortoiliac occlusive disease developed intestinal infarction. In 14 patients (67%) the lesion affected the left colon. The overall 30-day mortality rate was 13% but reached 67% among those with intestinal infarction. We conclude that acute intestinal ischemia with bowel infarction is an infrequent but serious complication of abdominal aortic surgery. It is mainly related to surgery due to aneurysmal disease, and patients with occlusive aortoiliac disease present ischemic complications in the intestines less often. Hypotensive patients being treated for ruptured aneurysm are at greatest risk of intestinal ischemia.