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Open surgical repair of abdominal aortic aneurysms (AAAs) has been performed for over 40 years now with good results. However, the procedure continues to be high-risk with numerous potential complications. The AneuRx modular bifurcated endograft was one of the first to be tested to exclude AAAs via an endovascular approach. Data from multiple clinical trials show that treatment of AAAs with the AneuRx device is comparable to open repair with regards to mortality and may have improved short-term and long-term morbidities rates. The following review discusses clinical use of the AneuRx stent graft system from the initial clinical trial in 1996 to its current commercial use.

The ability to reliably gain access to the vascular system is fundamental to the performance of all endovascular diagnostic and therapeutic procedures. Competence with a variety of different access sites and techniques is essential if one is to be able to address the full spectrum of vascular disease and diversity of clinical circumstances. Although open surgical access is sometimes indicated, most endovascular procedures can and should be performed percutaneously, because this is the least invasive technique. Understanding the advantages, risks, and potential pitfalls of the various approaches influences the site of access chosen and whether a percutaneous or open arteriotomy technique is used. Furthermore, this knowledge permits efforts to minimize attendant risks and facilitates recognition of problems when they do occur. The net result is a procedure unspoiled by failure to gain access or avoidable access site complications.

This study was designed to determine whether clinical evaluation and color-flow duplex scanning (CFS) alone provide enough information for patients to undergo carotid endarterectomy (CEA) safely without preoperative cerebral angiography and to assess the appropriate role of CFS in the evaluation of extracranial carotid artery disease.During a 31-month period 167 patients (114 symptomatic and 53 asymptomatic) underwent CFS and angiography during evaluation for CEA. One hundred fifty-three patients were studied retrospectively, and 14 were studied prospectively. Data were reviewed to determine whether cerebral angiography added information not provided by duplex findings and, if so, did the results alter clinical management.Of the 167 patients studied, 149 underwent CEA and 18 were treated medically. Results of the two diagnostic modalities agreed perfectly in 82% of the patients, with 99% of the stenoses estimated by CFS being classified within one category of those measured with angiography. The sensitivity of CFS for detecting greater than 50% diameter-reducing stenoses of the internal carotid artery was 98%, and the positive predictive value was 99%. For detecting greater than 80% stenoses, CFS had a sensitivity of 84% and a positive predictive value of 95%. Clinical management was altered by angiographic findings in only seven patients (4%). False-positive results (n = 5) were due to poor scanning technique or interpreter error (n = 2), anatomic variations (n = 2), and unknown cause (n = 1). All false-negative results (n = 2) were due to poor scanning technique.Ninety-six percent of the patients in this study would have received appropriate clinical management based on neurologic history and the results of CFS alone. Our results indicate that CFS is sufficient for determining the need for surgery in patients being considered for CEA and can supplant cerebral angiography in nearly all clinical circumstances.

Duplex ultrasonography with distal cuff deflation was used to determine the presence and size of incompetent veins and compare the results with those of air plethysmography in patients with chronic venous insufficiency.Thirty-two legs underwent a detailed study with both modalities. Sixteen legs had venous ulceration, six had stasis dermatitis, and ten had symptomatic varicose veins without skin changes.Although the venous filling index (VFI) in limbs with ulcers (5.4 +/- 3.8 ml/sec) and dermatitis (7.7 +/- 4.6 ml/sec) was significantly higher (p0.05) than it was in limbs with varicose veins (2.6 +/- 1.7 ml/sec), there was a large amount of overlap. Only 13% of ulcerated legs had VFI greater than 10 ml/sec. Sixty-three percent of legs with ulcers, 33% of legs with dermatitis, and 90% of legs with varicose veins had VFIs less than 5 ml/sec. Mean ejection fractions (EFs) in the three groups were similar, ranging from 45% to 52%. Combining VFI and EF did not lessen the overlap between groups. Forty-one percent of limbs with ulcers or dermatitis had air plethysmography parameters in the normal or intermediate area (VFI5 ml/sec; EF40%), which in previous studies corresponded to an incidence of ulceration of only 2%. VFI had a significant but weak correlation (r = 0.39) with the diameter of incompetent veins at the knee and a somewhat stronger relationship (r = 0.55) with the diameter of lower leg veins. Total venous volume correlated moderately well with calf vein diameter (r = 0.75). The clinical status of the leg did not correlate with the diameters of incompetent veins at the knee or calf levels. All limbs with an obstructed outflow had EFs less than 60% and ulcers or dermatitis.We conclude that plethysmographic measurements of functional venous parameters (VFI,EF) do not discriminate well between limbs with uncomplicated varicose veins and limbs with ulcers or stasis dermatitis and that VFI correlates poorly with the presence of incompetent veins and their diameters. Both duplex scanning and plethysmography seem to be necessary for a complete evaluation of limbs with chronic venous insufficiency.

This retrospective study was undertaken to investigate the effect of presenting neurologic symptoms, vascular risk factors, and degree of contralateral internal carotid artery stenosis on subsequent stroke and death rates of patients with internal carotid artery occlusion (ICO).One hundred sixty-seven patients with ICO were evaluated over a 5-year period. Mean follow-up was 39 months. Initial symptoms included transient ischemic attack in 29 patients (17%), stroke in 71 patients (43%), nonhemispheric symptoms in 22 patients (13%), and no symptoms in 45 patients (27%). Ninety percent of the presenting strokes occurred ipsilateral to the ICO.During follow-up 54 (32%) patients died, 10 (19%) of stroke and 22 (41%) of heart disease. The 5-year cumulative survival rate was 63%. Subsequent neurologic events occurred in 26% of the patients. Thirty patients (18%) had a stroke during follow-up, of which 20 (67%) occurred ipsilateral to the ICO. The 5-year stroke-free rate was 76%. Patients who had a stroke had a less favorable 4-year stroke-free rate (67%) than those who had transient ischemic attack (92%) or those who originally had no symptoms (89%), p = 0.03 and p = 0.04, respectively. In addition, there was a trend towards a worse 5-year contralateral stroke-free rate in patients with contralateral stenosis of 50% to 99% (77%) compared with patients with less than 50% contralateral stenosis (94%), p = 0.08. Twenty patients underwent carotid endarterectomy on the nonoccluded side. There were no perioperative strokes or deaths. Carotid endarterectomy seemed to reduce the long-term stroke morbidity rate (p = 0.10) on the operated side in patients with 80% to 99% contralateral stenosis but did not perceptibly improve stroke-free rates on the occluded side or in patients with 50% to 79% stenosis.Patients with ICO have a variable prognosis. There is a significant incidence of subsequent stroke, which seems to be related to the presenting neurologic event and the degree of stenosis in the contralateral internal carotid artery.

This study was designed to determine whether the presence of ipsilateral carotid siphon stenosis influenced the risk of early and late stroke and death after carotid endarterectomy (CEA).The outcomes of patients with moderate (20% to 49%), severe (50%), and no siphon stenosis were compared over a 16-year period from April 1976 to February 1992. Complete angiographic data were available in 393 carotid arteries.Siphon stenosis was found ipsilateral to the CEA in 84 (21.4%) of the arteries. Most lesions were in the 20% to 49% diameter-reducing range (77.4%), with the remainder in the greater than 50% range (22.6%). There were no occlusions. The perioperative mortality rate was nearly identical for the groups with and without siphon stenosis, 0.0% versus 0.6%, respectively (p = 0.99). Perioperative stroke morbidity rates (no stenosis, 2.3%; moderate stenosis, 3.1%;50% stenosis, 5.3%) were acceptable and were not statistically different (p0.38). Late ipsilateral stroke-free rates were similar in the groups with and without siphon stenosis. The 5- and 7-year stroke-free incidences were 88.5% and 83.4% versus 94.9% and 94.9%, respectively (p0.20) for the two groups. Long-term ipsilateral stroke-free rates were not significantly different in the subgroups with moderate (20% to 49%) and hemodynamically significant (50%) siphon stenosis. The 3- and 5-year ipsilateral stroke-free rates were 96.7% and 87.9% versus 94.6% and 94.6%, respectively (p = 0.69). Late death was more common in the group with siphon stenosis than it was in the group without siphon stenosis, 23.8% versus 12.5% (p = 0.02). Heart disease was responsible for most late deaths, 47% in both groups. Late stroke-related deaths were infrequent: 1.3% in patients with and 0.0% in patients without siphon stenosis.Although carotid siphon stenosis seemed to be associated with a higher risk of late death, it did not alter the short- and long-term stroke morbidity rates after carotid endarterectomy significantly. We conclude that the presence of carotid siphon stenosis should not influence the decision to perform carotid endarterectomy in patients with the appropriate indications.

Although routine noninvasive surveillance is recommended after carotid endarterectomy (CEA), there are little data to show that identification and eradication of recurrent carotid artery stenosis are necessary to avoid the risk of subsequent neurologic complications.We reviewed our experience over a 16-year period in 380 consecutive patients undergoing 409 CEAs who underwent serial postoperative ultrasonic scanning at 6 weeks, 6 months, and 1 year after CEA and then yearly thereafter.Recurrent stenoses (or = 50% diameter reduction) were detected in 44 arteries (10.8%) during follow-up from 1 to 177 months (mean 42.0 months). Most (70.5%) occurred within 2 years of CEA. Cumulative recurrence rates were 5.8%, 9.9%, 13.9%, and 23.4% at 1, 3, 5, and 10 years, respectively. Recurrent stenoses were more frequent in female (p = 0.02) and younger patients (p = 0.01) and less frequent in those having a vein patch repair (p = 0.02). Most recurrences (84%) were in the 50% to 79% stenosis range. In four patients 80% to 99% stenoses developed and in three patients total occlusions developed, for a severe recurrence rate of 2.1%. Only 10 (22.7%) of the recurrent stenoses were initially symptomatic, and only one (2.9%) of the asymptomatic restenoses later became symptomatic. One patient with recurrent stenosis suffered a stroke (0.3%). Cumulative 5-year ipsilateral stroke-free rates in patients with recurrent stenosis (94.4%) were practically identical (p = 0.76) to those in patients without recurrent stenosis (94.2%). Life-table ipsilateral stroke-free survival rates at 5 years were 94.2% in patients with recurrent stenosis and 78.4% in patients without recurrent stenosis (p = 0.16). Four (9%) recurrent stenoses and 12 lesions (27%) in the contralateral artery progressed. Only seven patients (1.7%) underwent repeat operation for ipsilateral disease, four for symptoms and three for recurrent stenosis.Recurrent carotid artery stenosis occurs early after CEA, is typically benign, and remains stable over a prolonged follow-up period. Our results question the importance of routine noninvasive surveillance after CEA and suggest that a more conservative approach would be equally beneficial in terms of clinical relevance and cost-effectiveness.

To determine the short- and long-term benefits of carotid endarterectomy (CEA) contralateral to an occluded internal carotid (ICA), we reviewed our experience since 1976.In 66 (13.8%) of 478 patients undergoing 544 CEAs, the contralateral ICA was occluded. Mean follow-up was 50.1 months (range, 1 to 165 months). Complete follow-up was available in 83.0% of patients.Operative death occurred in one (1.5%) of 66 patients with contralateral occlusion and six (1.3%) of 478 patients without contralateral occlusion (p = 0.99). Operative strokes occurred in two (3.0%) of 66 patients with contralateral occlusion and 14 (2.9%) of 478 without contralateral occlusion (p = 0.99). Life-table stroke-free rates at 1, 3, 5, and 8 years were 96.8%, 93.0%, and 93.0% in patients with contralateral occlusion and 95.9%, 94.2%, 91.1%, and 88.0% in patients without contralateral occlusion (p = 0.36). Five- and 8-year stroke-free rates were 100% and 100% in the asymptomatic subgroup with occlusion, 95.9% and 92.2% in the asymptomatic subgroup without occlusion (p = 0.45), 91.2% and 91.2% in the symptomatic subgroup with occlusion, and 89.7% and 86.8% in the symptomatic subgroup without occlusion (p = 0.47). Life-table survival rates at 5 and 8 years were 72.5% and 56.0% in patients with contralateral occlusion and 81.8% and 69.0% in patients without contralateral occlusion (p = 0.15).CEA performed in patients with and without symptoms with a contralateral ICA occlusion produces short- and long-term mortality and stroke morbidity rates comparable to those of similar patients without contralateral ICA occlusion. The indications for CEA in patients with contralateral ICA occlusion should not differ from those applied to patients without contralateral occlusion.

To determine whether carotid endarterectomy (CEA) safely and effectively maintained a durable reduction in stroke complications over an extended period, we reviewed our data on 478 consecutive patients who underwent 544 CEA's since 1976. Follow-up was complete in 83% of patients (mean 44 months). There were 7 early deaths (1.3%), only 1 stroke related (0.2%). Perioperative stroke rates (overall 2.9%) varied according to operative indications: asymptomatic, 1.4%; transient ischemic attacks (TIA)/amaurosis fugax (AF), 1.3%; nonhemispheric symptoms (NH), 4.9%; and prior stroke (CVA), 7.1%. Five and 10-year stroke-free rates were 96% and 92% in the asymptomatic group, 93% and 87% in the TIA/AF group, 92% and 92% in the NH group, and 80% and 73% in the CVA group. Late ipsilateral strokes occurred infrequently (8 patients, 1.7%). Late deaths were primarily cardiac related (51.3%). Stroke-free rates were significantly (p less than 0.0001) greater than stroke-free survival rates, confirming a non-stroke related cause for late death. Restenoses greater than 50% according to duplex scanning developed in 13%, most (67%) within 2 years after CEA. Most of these (77%) were asymptomatic, and only 0.3% (1 patient) presented with a permanent neurologic deficit. The results of carotid endarterectomy are superior to those of optimal medical management in symptomatic and asymptomatic patients in terms of long-term stroke prevention. When low perioperative stroke mortality/morbidity rates are achieved, carotid endarterectomy is justified for treatment of patients with carotid bifurcation disease.

Results of 253 consecutive bypass grafts to infrapopliteal arteries were reviewed. Most (92%) were placed for rest pain (103) or tissue loss (130). Autogenous veins were used in 175 (69%) cases, composite vein-prosthetic grafts were used in 45 (18%), and prosthetic grafts alone were used in 33 (13%). Follow-up ranged from 0 to 101 months (mean, 19 months); 37 grafts (15%) were lost to follow-up. The operative mortality rate was 4%, and 5-year patient survival rate was 44%. Limb salvage was 82% at 5 years. The 5-year patency of vein grafts (63%) exceeded that of both composite (28%) and prosthetic (7%) grafts (p = 0.005 and p = 0.00007, respectively); but the patency of composite and prosthetic grafts did not differ significantly (p = 0.29). The patency of reversed vein (59%) and in situ vein grafts (74%) was not significantly different at 5 years (p = 0.34). Patency was also not affected by the site of the proximal or distal anastomoses or diabetes. The major determinant of long-term patency in infrapopliteal reconstructions continues to be graft material. Composite grafts offered no clear advantage over prosthetic grafts, and both should be used only when there is no other alternative to amputation.

To determine whether color-flow imaging enhances the accuracy of noninvasive carotid evaluation, the results of carotid duplex examinations from two laboratories, one with color-flow and the other with standard duplex imaging were compared. The techniques used by both laboratories were identical. All studies were interpreted by one of the authors, using the same criteria. From October 1988 through December 1989, 307 internal carotid arteries were evaluated with both color-flow imaging and standard angiography; and 206 underwent routine duplex scanning and angiography. Perfect agreement between test and angiographic results was significantly better with color-flow (86.6%) than with conventional duplex scanning (79.6%), p = 0.034 (t test for independent samples). Significantly fewer vessels were over classified by one category with color-flow (8.5%) than with routine duplex scanning (16.5%), p = 0.006. However, no difference was found in the number under-classified by one category (4.5% vs 3.4%), p = 0.5. Although these data support the accuracy of both modalities, there appears to be a trend toward improved results with the newer method. We attribute this to more precise placement of the pulsed Doppler sample volume afforded by the color-flow image.

Seventy-eight infrainguinal grafts were evaluated by means of color-flow duplex imaging to demonstrate its utility in the routine surveillance of leg grafts as well as in the evaluation of grafts in which a problem is already suspected. Stenoses were identified in 15 (20%) of 76 grafts evaluated for screening purposes. Seven of these had confirmatory arteriograms, and five were revised. The remaining eight grafts with suspected stenoses were followed without angiography, and four (50%) subsequently failed. Only two (3.3%) of 61 grafts with normal scan outcomes have thrombosed. Fistulas were identified in 12 (37%) of 32 in situ grafts evaluated. Nine grafts with previously suspected problems based on decreased ankle-brachial indexes were scanned, and an explanation was found, confirmed by angiogram, and corrected in six. Detection of unsuspected stenoses in five grafts requiring revision and four grafts that later thrombosed without revision, as well as identification of fistulas in 37% of in situ grafts, confirms the importance of color-flow imaging as a screening tool.

A simple technique is described to reduce the size of the skin defect resulting from excision of a malignant melanoma. An added advantage of this technique is the smoother contour at the native skin to skin graft junction. These effects are achieved by apposing the skin edge to the muscle using a simple pursestring suture technique which simultaneously draws the wound edges centrally. The resultant smaller area to be grafted, smaller donor site, better graft survival and superior cosmesis represent an improvement over conventional skin grafting techniques.

An unusual case is reported of severe buttock claudication in a woman with normal ankle systolic pressures after exercise, for which the cause was eventually found to be isolated bilateral hypogastric arterial stenosis. Although a normal ankle pressure response to exercise usually rules out vascular obstruction in patients with symptoms suggestive of intermittent claudication, the diagnosis of isolated hypogastric arterial disease should be entertained when a neurogenic or orthopedic explanation can be excluded.