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Introduction: Arterial dissection commonly affects the thoracic aorta and is associated with high morbidity and mortality rates. Although dissection of the abdominal aorta is considered rare, liberal use of diagnostic computed tomographic scan imaging for evaluation of abdominal pain has identified this process with increasing frequency. Because the clinical features and therapeutic options of isolated abdominal aortic dissection are not well characterized, we reviewed our recent experience and provide an algorithm for treatment. Patients and Results: Since 1996, we have treated 10 patients with abdominal aortic dissection. The mean age was 62 ± 17 years, and 40% were female. Presentation included abdominal pain in seven patients and lower extremity ischemia in one patient. Dissection was asymptomatic in two of the patients. Hypertension, smoking history, remote trauma, and claudication were noted in four, three, two, and two of the patients, respectively. Three patients had abdominal tenderness, three had a pulsatile mass, and five had a benign abdominal examination. The diagnosis of dissection was made on abdominal computed tomographic scan in eight cases, on arteriogram in one case, and at operation in one case. No patient had an associated thoracic aortic dissection. The dissection flap originated below or at the renal arteries in nine of the cases and at the superior mesenteric artery in one case. Length of the dissection ranged between 21 and 110 mm, and in three patients, the dissection flap extended beyond the aortic bifurcation into the common iliac arteries. In three patients who had an aortogram, evidence of flow limitation was found on the basis of the presence of aortic stenosis or occlusion. Treatment consisted of aortic stent graft deployment in one patient, direct aortic reconstruction in three patients, and observation in the remaining six patients. Conclusion: Although the natural history of isolated abdominal aortic dissection has not been well defined, our experience adds to the understanding of this rare process. Because aneurysmal degeneration can occur, close surveillance is indicated if definitive treatment is not used initially. Patients with ischemic symptoms and those with intractable pain need intervention, the nature of which should be based on risk profile and aortoiliac anatomy. (J Vasc Surg 2002;36:205-10.)

Hemosuccus pancreaticus—blood entering the gastrointestinal tract through the pancreatic duct—is a rare and elusive form of gastrointestinal bleeding. The most common cause is a splenic artery pseudoaneurysm caused by acute or chronic inflammation of the pancreas. We report the case of an 86-year-old woman who had recurrent gastrointestinal bleeding from erosion of an aneurysm of the splenic artery into the pancreatic duct. The lack of associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Nonresective treatment by ligation of the splenic artery proximal and distal to the aneurysm prevented any additional bleeding. Postoperative technetium sulfur colloid scanning demonstrated normal perfusion of the spleen. Only 16 cases of hemosuccus pancreaticus from primary splenic artery disease have previously been reported in the English-language literature (15 primary aneurysms, one medial disruption without an aneurysm). In contrast to cases caused by inflammatory pseudoaneurysms, splenic artery - pancreatic duct fistulas caused by primary aneurysms of the splenic artery should be treated without pancreatic or splenic resection, either with surgery or by embolization. In elderly patients with recurrent gastrointestinal bleeding of obscure source, the differential diagnosis should include the possibility of a ruptured aneurysm communicating with a viscus. (J VASC SURG 1994;19:158-64.)

Purpose: Vascular clamps, vessel loops, and intraluminal occluding devices used to control tibial and pedal vessels can be injurious and may fail to occlude heavily calcified arteries. In an effort to prevent injury to these small arteries, we have investigated the safety and efficacy of thigh pneumatic tourniquet occlusion for distal vascular control during infrapopliteal reconstruction. Methods: During an 18-month period, 88 tibial or pedal arterial reconstructions were performed on 80 patients (mean age 75 years) by the tourniquet technique. Data regarding indications for operation, preoperative evaluation, intraoperative findings, surgical technique, and early outcome were recorded prospectively. Results: Sixty percent of patients were diabetic: 36% insulin dependent and 24% non-insulin dependent. The indications for operation were claudication in 6 (7%), ischemic ulcer in 24 (27%), rest pain in 25 (28%), and gangrene in 33 (38%) patients. Thirty-five percent of operations followed failed ipsilateral infrainguinal reconstructions. The peroneal artery was the target vessel in 38%, anterior tibial in 26%, posterior tibial in 23%, tibioperoneal trunk in 9%, and inframalleolar vessels in 4% of cases. Preoperative analog waveforms and ankle-brachial indexes were used to classify the tibial arteries as compliant, 49%; relatively noncompressible, 30%; and absolutely noncompressible, 9%. Twelve percent had no Doppler flow at the ankle level. At operation 36 of the target arteries (41%) had mural calcification. Tourniquet pressures of 200 to 400 mm Hg (mode 250 mm Hg) were applied from 13 to 55 minutes (mean 27.1 ± 9.1 minutes). All patients were given systemic anticoagulants. In 19 limbs (22%) the tourniquet was used to occlude a patent superficial femoral artery above the proximal (inflow) anastomosis to either the superficial femoral artery (8%), the above-knee popliteal artery (5%), or the below-knee popliteal artery (9%). Hemostasis was adequate in all cases and no alternative occlusive devices were required. There were no significant complications attributable to the use of the pneumatic tourniquet. Conclusion: Tourniquet occlusion simplifies the infrapopliteal dissection, lessens operating time, improves visualization of the distal anastomosis, and removes the potential for arterial injury to the target vessel. Arterial calcification and noncompressible tibial arteries do not contraindicate the use of thigh tourniquet occlusion. This technique is preferred for all patients undergoing tibial or pedal artery reconstruction. J VASC SURG 1993;18:637-47.)

The influence of neutralizing or not neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma is unknown. During the past 6 years some of the authors frequently gave protamine sulfate to neutralize heparin, whereas others did not unless a patch was used or wound hemostasis was not readily obtained. To determine the influence of protamine sulfate on stroke and wound hematoma the records of 697 patients having a carotid endarterectomy from January 1984 to September 1989 were reviewed. Protamine sulfate was given to 328 patients, and 369 did not receive protamine sulfate. The incidence of stroke in the two groups was 1.8% (n = 6) and 2.7% (n = 10), respectively, and the difference was not significant (p = 0.6019). Excluding three strokes that could not be related to neutralizing or not neutralizing heparin, the difference remained insignificant (1.5% vs 2.2%, p = 0.7290). The incidence of wound hematoma was 1.8% (n = 6) in patients given protamine sulfate and 6.5% (n = 24) in patients not given protamine sulfate, and this difference was significant (p = 0.0044). The difference remained significant when three hematomas not related to protamine sulfate were excluded (1.2% vs 6.2%, p = 0.0013). In patients not given protamine sulfate draining the wound lessened the incidence of wound hematoma (4.4% vs 8.6%), but this difference was not statistically significant (p = 0.1475). In patients given protamine sulfate the dose of protamine sulfate (15 to 45 mg vs 50 to 75 mg) had no statistically significant effect on the incidence of stroke (0.8% vs 2.0%, p = 0.6530) or wound hematoma (1.6% vs 1.0%, p = 1.000).

Introduction Cryopreserved saphenous vein allografts (Cryograft; CryoLife, Kennesaw, Ga) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Although some studies of Cryografts report poor long-term patency, an anticoagulation protocol may improve outcome. We evaluated our experience with Cryografts to further define their role in lower extremity revascularization. Patients and methods Between March 1992 and March 2002, 240 infrainguinal revascularization procedures with Cryografts were performed in 199 limbs of 177 patients. Eighty-nine percent of procedures were performed because of ischemic rest pain or tissue loss, and 75% of vein grafts were implanted into infrapopliteal targets. Most patients received anticoagulation therapy with warfarin sodium or aspirin, or both, postoperatively. Mean age of the cohort was 78 years; 61% were women; 75% had hypertension, 58% had diabetes, and 38% had renal dysfunction; and 47% were current or past smokers. Results Mean follow-up was 7 months (range, 0-48 months). Primary patency rate was 83% at 1 month, 50% at 6 months, 30% at 12 months, and 18% at 24 months. Diabetes adversely affected graft patency. Warfarin sodium or antiplatelet therapy did not significantly improve graft patency. Limb salvage was 80% at 1 year and 71% at 2 years. Conclusions Cryografts have low primary patency rates that are not affected by anticoagulation with warfarin sodium. Short-term patency of these grafts may be sufficient to heal ischemic wounds and thereby prevent limb loss. However, other less expensive alternatives, eg, prosthetic grafts with vein cuffs, are available and appear to have better patency. Accordingly, use of Cryografts should be limited to revascularization through infected fields in patients without autogenous conduit.

Purpose: This study was undertaken to compare repeat percutaneous transluminal angioplasty (rPTA), arterial reconstruction, and noninvasive therapy for treatment of patients with recurrent stenosis after PTA of the superficial femoral or popliteal artery. Methods: From 1983 to 1993, 93 patients were treated for recurrent femoropopliteal stenosis. Indication for treatment was claudication in 72 patients, rest pain in 9, and ischemic ulcer in 12. Thirty-six patients (38%) were treated with arterial bypass, 35 (38%) with rPTA, and 22 (24%) with exercise and medication. Patients were monitored with clinical examination, ankle-brachial indexes, and duplex scanning. Follow-up ranged from 6 to 110 months (mean 42 months). Results: With life-table analysis, the clinical and hemodynamic success of patients treated with rPTA was 41% at 1 year, 20% at 2 years, and 11% at 3 years. For patients treated with arterial bypass, the primary graft patency rate was 84%, 72%, and 72% at 1, 2, and 3 years, respectively. The secondary graft patency rate was 94%, 88%, and 88% at the same intervals. All patients with patent grafts were symptom free. All 22 patients treated with noninvasive therapy continued to have symptoms, but none required amputation during follow-up (range 6 to 108 months). Overall, patients with claudication did better than those treated for rest pain or an ischemic lesion after either rPTA or arterial bypass, but no other variable was statistically significant in predicting outcome. Conclusions: This study finds that arterial bypass is safe and more effective than rPTA in treating patients with recurrent stenosis. Preoperative evaluation is unable to select patients likely to benefit from rPTA. Repeat PTA should be reserved for patients with limited life expectancy or contraindications to operation. (J VASC SURG 1994;20:577-87.)

Anastomotic false aneurysm (AFA) of the aorta or iliac artery is a potentially lethal complication of prosthetic grafts. To study this complication, the records of 18 patients with 22 noninfected AFAs (15 aortic and seven iliac) were reviewed. Patients with an intact AFA had a pulsatile abdominal mass, abdominal pain, an occluded graft, peripheral emboli, or a femoral anastomotic false aneurysm. All patients with a ruptured AFA were in shock, but 67% (four of six) had symptoms before hemorrhage. For diagnosis, single-plane angiography was 69% accurate (11 of 16), computed tomography was 100% accurate (six of six), and ultrasound was used once and suggested an AFA. Three patients with an AFA less than 5 cm diameter were initially observed; however, all three aneurysms rapidly enlarged and one ruptured. The operative mortality rate was 8% (1 of 12) for patients with an intact aneurysm and 67% (four of six) for patients with a ruptured aneurysm. Treatment was resection of the AFA and replacement with a new graft. Retroperitoneal AFAs often appear years after the initial operation, and life-long follow-up is required for patients with an aortic or iliac graft. All retroperitoneal AFAs should be resected since the outcome of patients with a ruptured AFA is poor. (J VASC SURG 1988;8:268-73.)

Near-total or total blindness caused by chronic ocular ischemia is a well-recognized complication of severe atherosclerotic occlusive disease of the carotid artery (CA) but has not been previously reported in the English-language literature as a sequela of an occlusive CA injury. This report describes a patient who sustained a gunshot wound to the neck, which injured the ipsilateral internal CA, external CA, and vertebral artery. The location of the injuries precluded arterial repair. The patient was neurologically intact after operative exploration. Twenty months after the injury a marked loss of vision in the ipsilateral eye was detected. Chronic ocular ischemia was diagnosed from clinical findings and ophthalmoscopic examination results. Knowledge that chronic ocular ischemia and blindness can occur after an occlusive CA injury supports the use of primary arterial repair for all CA injuries. In those instances in which repair is not technically possible, frequent ophthalmoscopic examinations and testing of visual acuity should be used postoperatively to diagnose ocular ischemia; thus treatment to prevent the loss of sight can be carried out.

Color flow duplex scanning was used to "map" the iliofemoral and femoral popliteal segments in 61 patients (84 extremities) undergoing evaluation for excimer laser angioplasty. Eight locations, iliac, common femoral, profunda femoris, proximal and distal superficial femoral artery, proximal and distal popliteal, and tibioperoneal trunk were scored as normal versus abnormal, greater than 50% stenosis, or occluded, and occlusions were measured in centimeters. Specificity, sensitivity, and accuracy were calculated with the arteriogram as the gold standard (83% and 96%, respectively, for normal vs abnormal, 87% and 99% for 50% stenosis, and 81% and 99% for occlusions). Color flow accurately identified the presence and extent of occlusions in 48 of 51 extremities (94%) when compared to arteriography plus operative findings, since arteriography alone tended to overestimate occlusion length. It is concluded that color flow Doppler alone may be used to screen patients with peripheral vascular disease to assess candidacy for endovascular procedures without antecedent arteriography, and that arteriography alone would exclude some patients from consideration by falsely overestimating occlusion lengths.

Purpose: This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis. Methods: The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined. Results: Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD. Conclusions: Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD. (J Vasc Surg 1996;24:597-607.)