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Background: This study evaluated the feasibility, safety, and effectiveness of endovascular interventions for common femoral artery (CFA) occlusive disease., Methods: Using a prospectively maintained multicenter database, we analyzed outcomes in 167 consecutive patients who underwent percutaneous CFA interventions for Rutherford class 3 to class 6 (R3-R6) disease. The standardized treatment approach included primary percutaneous transluminal angioplasty (PTA) only, atherectomy + PTA, and provisional stenting. Outcomes included technical failure rate, recurrence, complications, and major or minor amputation rate. Data were analyzed using multivariate regression analysis., Results: During a 7-year period, 167 patients with R3 (n = 91 [54.5%]) and R4 to R6 (n = 76 [45.5%]) disease underwent CFA interventions that included PTA only (n = 114 [68.2%]), atherectomy ± PTA (n = 38 [22.8%]), and provisional stenting (n = 15 [9.0%]) for failed atherectomy ± PTA. Procedure-related complications included pseudoaneurysm (n = 1 [0.6%]), thrombosis (n = 1 [0.6%]), distal embolization (n = 1 [0.6%]), and death (R6, n = 1 [0.06%]). CFA restenosis was observed in 34 (20.4%) patents; these underwent further percutaneous (n = 18 [10.8%]) or surgical (n = 17 [10.2%]) revascularization that included CFA endarterectomy ± femoral distal bypass. Major or minor amputations were observed in none of the R3 patients and in only three (3.9%) and five (6.5%) of the R4 to R6 patients, respectively. Compared with the atherectomy + PTA group, patients in the PTA-only group had a significantly lower patency. Furthermore, during long-term mean follow-up of 42.5 months, the CFA provisional stent group had a 100% primary patency, which was significantly better than the primary patency in the CFA nonstent groups combined (77.0%; P = .0424)., Conclusions: Data from this study to date would suggest that percutaneous CFA interventions in select patients are relatively safe and effective. In the long term, CFA stenting has significantly better primary patency than CFA atherectomy and PTA combined. CFA atherectomy + PTA has significantly better primary patency than CFA PTA-only at midterm, especially in patients with claudication. Future randomized controlled trials are warranted., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined the effect of acute ischemic stroke (AIS) care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA)., Methods: A standardized AIS protocol was instituted between vascular surgery and stroke neurology services in an academic hospital (group I) that included: (1) rapid patient evaluation and imaging inclusive of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound imaging or conventional arteriogram, or both; (2) patient admission to a dedicated stroke unit with minimum 1:2 intensive care nurse-to-patient staffing and a 24-hour available neurointensivist; (3) treatment of all patients with ipsilateral moderate or severe carotid stenosis by CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from undergoing expeditious CEA included (1) stroke in evolution, and (2) dense neurologic deficit or National Institutes of Health Stroke Scale score >15 (severe), or both. Comparisons of data were performed between group I patients and those treated in outlying hospitals (group II) for similar indications. All data were prospectively collected in a computerized database and outcomes evaluated retrospectively., Results: From November 2002 to November 2012, 369 patients underwent CEA for AIS ≤1 week of presentation. There were 192 patients in group I and 177 in group II. There were no differences in group I and II in mean stroke-to-CEA interval (3.4 vs 3.9 days) or in the performance of eversion CEA (94% vs 97%), respectively. Intraoperative shunt use was greater in group I (28%) than in group II (18%; P = .021). Fewer total neurologic events (stroke or transient ischemic attack) occurred in group I (6 [3.1%] vs 14 [7.3%]; P = .03). No patients died in either group. Postoperative National Institutes of Health Stroke Scale scores available in group I patients showed improvement from preoperative baseline in mild and moderate stroke patients (P < .001)., Conclusions: In patients with stable acute stroke, early CEA is feasible and relatively safe. Stroke or death occurs in only 1%, and most complications are of nonfatal cardiac origin. A standardized stroke team protocol that is inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of an acute stroke., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Endovascular aneurysm repair (EVAR) is now the standard of care for elective infrarenal and ruptured abdominal aortic aneurysms (AAAs). Difficult proximal necks often require adjuvant measures to seal type 1 endoleaks. We believed this was a predictor of increased 30-day morbidity and mortality and reduced long-term survival., Methods: We reviewed outcomes for all patients entered into our database between 2003 and 2010 who had EVAR for elective or ruptured AAAs. Patient demographics and operative indications were recorded. Operative procedures, including adjuvant procedures, such as Palmaz XL stent deployment, were documented. All postoperative deaths and morbidity were recorded. Long-term survival was calculated using life table analysis. Multivariate analysis was performed to determine significant predictors of early mortality., Results: Between 2003 and 2010, 1470 patients underwent EVAR for AAA (1378 [93.7%] elective; 92 [6.3%] ruptured or emergent). Elective EVAR patients required Palmaz stent placement in 146 of 1378 (10.6%) cases; in emergent cases, Palmaz stents were required in 16 of 92 (17.4%) cases. This was not significantly different (P=0.06). Thirty-day mortality for elective EVAR was 1.6% (22/1378) compared with 21.7% (20/92) for emergent repair (P<0.0001). Thirty-day mortality among the 146 elective patients undergoing Palmaz stenting was 3.4% compared with 1.4% in the 1232 non-Palmaz stent elective EVAR patients (P=0.085). In emergency cases, the 30-day mortality for the 16 Palmaz patients was 25% compared to 21% for the 76 non-Palmaz stent patients (P=0.76). Among 30-day survivors, there were 428 of 1356 (31.6%) endoleaks identified in the elective patient group and 36 of 72 (50%) in the emergency group (P<0.005). Of the 146 elective patients requiring insertion of a Palmaz stent, 65 (44%) developed endoleaks, significantly more than the 370 of 1232 (30%) in non-Palmaz elective patients (P=0.0004). Among the emergency group, there were also significantly more endoleaks among the 30-day survivors who had a Palmaz stent deployed. In elective EVAR requiring Palmaz XL stents, 14% still had type 1 endoleaks at the end of their procedure; 13% still had type 1 endoleaks in the rupture EVAR Palmaz group. Multivariate analysis of all patients found that while female sex, AAA diameter, and estimated blood loss predicted 30-day mortality, deployment of a Palmaz stent did not. Long-term survival among Palmaz patients was not significantly different from non-Palmaz patients in the elective or emergent setting, although Palmaz patients required more secondary interventions., Conclusions: During EVAR, deployment of a Palmaz stent is more frequently required in patients with rupture, female sex, and larger sac size. However, Palmaz stent deployment itself is not an independent predictor of increased 30-day mortality in either the elective or emergency setting or of poorer long-term survival. However, they are associated with a greater number of postoperative endoleaks, especially type 1 endoleaks, and predict a greater need for secondary interventions., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To date, there are no published reports comparing hemodynamically (Hd)-stable and Hd-unstable patients with ruptured abdominal aortic aneurysms (r-AAAs) undergoing endovascular aneurysm repair (EVAR). This study evaluates outcomes of EVAR for r-AAA based on patient's Hd status, Methods: From 2002 to 2011, 136 patients with r-AAAs underwent EVAR and were categorized into two groups based on systolic blood pressure (SBP) measurements before EVAR: 92 (68%) Hd-stable (SBP ≥ 80 mm Hg) and 44 (32%) Hd-unstable (SBP <80 mm Hg for >10 minutes). All data were prospectively entered in a database and retrospectively analyzed. Outcomes included 30-day mortality, postoperative complications, the need for secondary reinterventions, and midterm mortality. The effect of potential predictors on 30-day mortality was assessed by χ(2) and logistic regression., Results: Of the 136 r-AAA patients with EVAR, the Hd-stable and Hd-unstable groups had similar comorbidities (coronary artery disease, 63% vs 59%; hypertension, 72% vs 75%; chronic obstructive pulmonary disease, 21% vs 26%; and chronic renal insufficiency, 18% vs 18%), mean AAA maximum diameter (6.6 vs 6.4 cm), need for on-the-table conversion to open surgical repair (3% vs 7%), and incidences of nonfatal complications (43% vs 38%) and secondary interventions (23% vs 25%). Preoperative computed tomography scan was available in significantly fewer Hd-unstable patients (64% vs 100%; P < .05). Compared with Hd-stable patients, the Hd-unstable patients had a significantly higher intraoperative need for aortic occlusion balloon (40% vs 6%; P < .05), mean estimated blood loss (744 vs 363 mL; P < .05), incidence of developing abdominal compartment syndrome (ACS; 29% vs 4%; P < .01), and death (33% vs 18%; P < .05). ACS was a significant predictor of death; death in all r-EVAR with ACS was significantly higher compared with all r-EVAR without ACS (10 of 17 [59%] vs 22 of 119 [18%]; P < .01)., Conclusions: EVAR for r-AAA is feasible in Hd-stable and Hd-unstable patients, with a comparable incidence of conversion to open surgical repair, nonfatal complications, and secondary interventions. Hd-stable patients have reduced mortality at 30 days, whereas Hd-unstable patients require intraoperative aortic occlusion balloon more frequently, and have an increased risk for developing ACS and death., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Endovascular aneurysm repair (EVAR) decreases 30-day mortality for patients with ruptured abdominal aortic aneurysms (r-AAAs) compared with open surgical repair (OSR). However, which patients benefit or whether there is any long-term survival advantage is uncertain., Methods: From 2002 to 2011, 283 patients with r-AAA underwent EVAR (n = 120 [42.4%]) or OSR (n = 163 [57.6%]) at Albany Medical Center. All data were collected prospectively. Patients were analyzed on an intention-to-treat basis, and outcomes were evaluated by a logistic regression multivariable model. Kaplan-Meier analysis was used to compare long-term survival., Results: The EVAR patients had a significantly lower 30-day mortality than did the OSR patients (29/120 [24.2%] vs 72/163 [44.2%]; P < .005) and better cumulative 5-year survival (37% vs 26%; P < .005). Men benefited more from EVAR (mortality: 20.9% for EVAR vs 44.3% for OSR; P < .001) than did women (mortality: 32.4% vs 43.9%; P = .39). Age ≥80 years was a significant predictor of death for EVAR (odds ratio [OR], 1.07; P = .003) but not for OSR (OR, 1.04; P = .056). Preexisting hypertension was a significant predictor of survival for both EVAR (OR, 0.17; P < .001) and OSR (OR, 0.48; P = .021). Almost one fourth of EVAR patients (21/91 [23.1%]) required secondary interventions. Survival advantage was maintained for EVAR patients to 5 years., Conclusions: For r-AAA, EVAR reduces the 30-day mortality and improves long-term survival up to 5 years. However, whereas open survivors require few graft-related interventions, up to 23% of EVAR patients will require reintervention for endoleaks or graft migration. Close follow-up of all EVAR survivors is mandatory., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Women have a lower chance of surviving elective open abdominal aortic repair. The reasons for this are not clear. Endovascular repair has clearly reduced early and midterm morbidity and mortality for patients with large abdominal aortic aneurysms (AAAs). However, most patients are male. It is unclear whether there has been any reduction in elective morbidity for females or what the extent of that reduction has been. We prospectively analyzed outcomes for elective endovascular aneurysm repair (EVAR) in women at our center and compared results with those for elective open surgery and emergent open and endovascular repair., Methods: All patients undergoing elective and emergency AAA from 2002 to 2009 were prospectively entered into a database. Demographic details, including gender, were tabulated. Outcome measures were operative blood loss, incidence of type 1 endoleaks, length of in-hospital stay, postoperative complications, 30-day all-cause mortality, and secondary interventions during the follow-up period. Statistical analysis was performed using Fischer exact test and Student t test. A multivariate analysis was also performed., Results: From 2002 to 2009, there were 2631 abdominal aortic aneurysms (AAA) open and endovascular repairs performed in our center (1698 endovascular aneurysm repairs [EVARs], 933 "open"). Males comprised 1995 (76%) of patients; females 636 (24%). There were 1592 elective EVARs (1248 male, 344 female) and 106 emergency EVARs (73 male, 33 female). Elective open repair was performed in 788 patients (579 male, 209 female) and emergency open repair in 149 (73 male, 76 female). For women, elective EVAR resulted in significantly greater mortality rates than men (3.2% vs 0.96%, P < .005). There was a greater incidence of intraoperative aortic neck or iliac artery rupture (4.1% vs 1.2% P = .002) and use of Palmaz stents for type 1 endoleaks (16.1% vs 8%, P = .0009). Mean blood loss was greater in females (327 mL vs 275 mL, P = .038). Perioperative complications were also more frequent in women: leg ischemia (3.5% vs 0.6%, P = .003) and colon ischemia requiring colectomy (0.9% vs 0.2%, P = .009). Mean hospital stay was also longer (3.7 days vs 2.2 days, P = .0001). In contrast, there were no gender differences for any of these outcome measures for elective open repair or emergency open surgery or EVAR. There was no significant difference in death rates between EVAR and open repair in women (3.2% vs 5.7%). In males, the 30-day mortality was 0.96% for elective EVAR and 4.7% for elective open surgery. Following logistic regression, female gender remains a significant risk even when the effects of aneurysm size and age are considered (odds ratio 3.4, P < .01)., Conclusions: Mortality for females undergoing elective EVAR is significantly greater than for males. It is also more hazardous. Colon ischemia, native arterial rupture, and type 1 endoleaks are more frequent. Elective endovascular aneurysm repair benefits men more than women., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: Delayed abdominal aortic aneurysm (AAA) rupture is a well recognized complication of endovascular aneurysm repair (EVAR). We wanted to evaluate the frequency, etiology, and outcomes of delayed AAA rupture following EVAR, and identify treatment options that facilitate improved survival., Methods: From 2002 to 2009, 1768 patients underwent elective and emergent EVAR. At a mean follow-up of 29 months, 27 (1.5%) patients presented with delayed AAA rupture and required repair by either open surgical conversion or endovascular means. All data were prospectively collected in a vascular registry, and outcomes analyzed., Results: Over a mean follow-up of 29 months, the incidence of delayed AAA rupture after elective EVAR was 1.4% (24 of 1615 patients), and after emergent EVAR for ruptured AAA was 2.8% (3 of 106 patients). Of the 27 delayed AAA rupture patients, 20 (74%) were considered "lost to follow-up," and, at presentation, 17 (63%) patients had Type 1 endoleak with stent graft migration, three (11%) had Type 1 endoleak without stent graft migration, five (19%) had Type 2 endoleak, and two (7%) had undetermined etiology for aneurysm rupture. Fifteen (55%) patients underwent open surgical repair via retroperitoneal approach with partial (n = 8; 53%) or complete (n = 7; 47%) stent graft explants and aortoiliac reconstruction, 11 (41%) patients underwent a second EVAR, and one (4%) patient refused treatment and died. Supraceliac aortic clamp was required in three (20%) patients with open surgical conversion, and supraceliac occlusion balloon was required in two (18%) patients with EVAR. There were three (11%) postoperative deaths; two following open surgical conversion and one following EVAR. One additional redo-EVAR patient has undergone successful elective conversion to open surgical repair for persistent type II endoleak and increase in AAA size., Conclusions: Delayed AAA rupture following EVAR can be successfully managed in most patients by open surgical conversion or secondary EVAR. The approach to each patient should be individualized; complete stent graft explant is not necessary in most patients; a secondary EVAR for delayed AAA rupture with or without an elective conversion to open surgical repair remains a viable option. Vigilant routine follow-up is needed for all patients after EVAR., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: This study evaluated the outcomes of secondary procedures after endovascular aneurysm repair (EVAR)., Methods: From 2002 to 2009, 1768 patients underwent EVAR for treatment of 1662 elective (94%) and 106 emergent (6%) infrarenal abdominal aortic aneurysm (AAA) with a variety of Food and Drug Administration-approved and commercially available stent grafts. Postoperative follow-up included clinical examination, pulse volume recording, duplex ultrasound imaging, and computed tomography and magnetic resonance angiography at 1, 6, and 12 months, and yearly thereafter. Patients with type I and III endoleaks, unexplained endotension, limb occlusion, stent graft migration, with and without type I endoleak, and aneurysm rupture underwent secondary interventions. Type II endoleak at >6 months without a decrease in the aneurysm sac underwent translumbar embolization. Data were prospectively collected., Results: EVAR was performed in 1768 patients. During a mean follow-up of 34 (SD, 30.03) months, 339 patients (19.2%) required additional secondary procedures for aneurysm-related complications, including type I (n = 51, 15.0%), type II (n = 136, 40.1%), and type III (n = 5, 1.5%) endoleaks; endotension (n = 8, 2.4%), stent graft migration proximal fixation site (n = 46, 13.6%), stent graft iliac limb thrombosis or stenosis (n = 25, 7.4%), subsequent iliac aneurysm formation (n = 39, 11.5%), or aneurysm rupture after EVAR (n = 29, 8.6%). The mean age was 74 (SD, 9.15) years. Mean AAA size was 5.7 (SD 3.24) cm. Compared with secondary procedures for AAA rupture, the nonrupture patients had a significantly lower mortality (1.6% vs 17.2%, P < .05) and a higher likelihood of being managed by endovascular means (98.8% vs 44.8%, P < .05). When nonruptured EVAR patients required urgent secondary procedures for type I endoleaks and stent graft migration or limb thrombosis, the mortality was 6.0% vs 0.5% for elective procedures (P < .05)., Conclusions: Our long-term EVAR experience indicates that 18% of patients require additional secondary procedures, and most of these patients can be managed by endovascular means with an acceptable overall mortality of 2.9%. Most type I and II endoleaks can be successfully treated by transluminal embolization, and most patients with delayed aneurysm rupture after EVAR can be successfully managed by endovascular or open surgical repair., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA)., Methods: Since 2004, 228 patients underwent TEVAR under elective (n=162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively., Results: Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n=20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n=2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n=3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair., Conclusions: Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: The average lifespan in the United States continues to lengthen. We have observed a similar trend in our patients, with an increased number of nonagenarians presenting for evaluation of vascular disease. This study evaluated outcomes of lower extremity revascularization in patients aged >or=90 years., Methods: The vascular registry at Albany Medical College was retrospectively reviewed for all lower extremity bypasses performed between 1996 and 2006. We evaluated patient demographics, indications, procedure, patency rates, and complications. Patients were divided into groups based on age >or=90 years (>or=90 group) and <90 years (<90 group). Variables were evaluated by chi(2) analysis. Outcomes were prepared using life-table methods and compared with log-rank analysis., Results: During the last 10 years, 5443 lower extremity bypasses were performed on patients aged <90 years and 150 on patients aged >or=90 years. The <90 group had significantly more men (61.4% vs 29.3%) and was obviously younger, at 68 years (range 7-89 years) vs 92 years (range, 90-101 years). The <90 group had more comorbidities in terms of diabetes, active tobacco use, and hypercholesterolemia. No significant difference was noted in coronary artery disease or chronic renal insufficiency between the groups. Critical limb ischemia as an indication was significantly higher in the >or=90 group (149 [99%] vs 4472 [82%]; P < .0.5). Strikingly, the primary patency was significantly higher in the >or=90 group at 4 years (77% vs 62%; P < .05). Complication and amputation rates did not differ between the groups. Perioperative (15% vs 3%; P < .05) and 1-year (45% vs 11%; P < .05) mortality rates were significantly higher in the >or=90 group., Conclusion: Lower extremity bypass for nonagenarians offers acceptable patency and limb salvage but at a significantly higher mortality rate.

Purpose: With the FDA approval of thoracic endografts, extra-anatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extra-anatomic reconstruction of the carotid and subclavian vessels., Methods: One hundred and forty three (143) procedures were performed for extra-anatomic carotid and subclavian reconstruction. Of these 143 operations: 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses, 30 were subclavian carotid reconstructions and 6 were carotid subclavian transpositions. Sixty (42%) were male, 20 (14%) were diabetic, and 63 (44%) were current smokers. Mean age was 63 (SD +/- 12.3). Indication for surgery was primarily for occlusive or embolic disease (97%). In those patients undergoing bypass graft, prosthetic (ePTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency., Results: Of the 143 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%., Conclusion: Extra-anatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require aortic "debranching" prior endovascular thoracic aortic aneurysm repair.

Purpose: Patients after infrainguinal vein bypasses are a group at risk of graft stenosis and occlusion. Revision of failing grafts has been shown to significantly improve bypass patency and limb salvage. Options for surgical revision of mid bypass stenosis includes either patch angioplasty (PA) or interposition grafting (IG). We reviewed our experience with surgical revision of vein bypass stenosis., Methods: From April 1968 to March 2006, 7557 autogenous vein bypasses were performed at Albany Medical Center and its affiliated institutions, of these 316 required single or multiple revision of vein grafts with patch angioplasty or interposition vein grafting. Excluded were proximal and distal anastomotic revisions. Only 235 bypasses had single revisions as either patch angioplasty (n = 108) or interposition grafting (n = 127) and are the focus of this review. The initial bypass revisions in these two groups are analyzed for indications, clinical parameters, operative strategies, and long-term patencies and clinical outcomes., Results: There were no significant differences in mean age, gender, or frequency of comorbid conditions (coronary artery disease, pulmonary disease, hypertension, and diabetes) between the two patient groups. Secondary patency of patch angioplasty revision at 5 years was 79%. Patencies for interposition grafting revision at 5 years were equivalent to patch angioplasty group at 75%. When bypasses were evaluated on the basis of initial reconstructions (ie, in situ vs excised vein bypass), the results showed that in situ bypasses that required initial revision had similar 5-year patencies when interposition grafting was used as the first revision strategy vs patch angioplasty (80% vs 73%). Excised vein bypasses had similar patency when patch was their first revision strategy vs interposition grafting (4 year secondary patency 92% vs 75% respectively)., Conclusion: Autogenous vein bypasses are at risk for developing significant stenosis and occlusion with time. Bypass stenosis that develops in the main body of the graft can be effectively repaired using either patch angioplasty or interposition grafting. Depending on the host of other factors, such as availability of autogenous venous conduit, location of stenosis, accessibility for operative repair, and the patient's anatomic characteristics, either operative strategy is effective in prolonging the patency of the bypass.

Purpose: Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD)., Methods: Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis., Results: Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22 patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant., Conclusion: In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.

Purpose: In our transition from elective abdominal aortic aneurysm (AAA) to emergent ruptured AAA (r-AAA) repair with endovascular techniques, we recognized that the availability of endovascularly trained staff in the operating rooms and emergency departments, and adequate equipment were the limiting factors. To this end, we established a multidisciplinary protocol that facilitates endovascular repair (EVAR) of r-AAA., Methods: In January 2002, we instituted a multidisciplinary approach that included the vascular surgeons, emergency department physicians, anesthesiologists, operating room staff, radiology technicians, and availability of a variety of stent-grafts to expedite EVAR of r-AAAs. Five patients with symptomatic, not ruptured AAAs suitable for EVAR underwent simulation of patients presenting to the emergency department with r-AAAs. Emergency department physicians alerted the on-call vascular surgery team (vascular surgeon, vascular resident or fellow) and the operating room staff, emergently performed an abdominal computed tomography (CT) scan in only hemodynamically stable patients with systolic blood pressures > or =80 mm Hg, and transported the patient to the operating room. The vascular surgeon informed the operating room staff to set up for EVAR and open surgical repair in an operating room equipped with interventional capabilities. The operating room setup was rehearsed with the anesthesiologists, operating room staff, and radiology technicians who were knowledgeable of the sequence of steps involved. Since then, 40 patients have undergone emergent EVAR for r-AAAs with general anesthesia., Results: No complications developed in any of the symptomatic (simulation) patients, and 40 (95%) of 42 patients with r-AAAs had a successful EVAR with Excluder (n = 27, 68%), AneuRx (n = 9, 23%), or the Zenith (n = 4, 10%) stent-grafts. The mean age was 73 years (range, 54 to 88 years), and pre-existing comorbidities included coronary artery disease in 26 (65%), hypertension in 23 (58%), chronic obstructive pulmonary disease in 7 (18%), renal insufficiency not on dialysis in two (5%), and diabetes in nine (23%). Fourteen (38%) patients were diagnosed with r-AAAs at another hospital and subsequently were transferred to us, and 26 (62%) presented directly to the emergency department at our institution. At the initial presentation, 30 patients (75%) were hemodynamically stable and either had a CT scan at an outside hospital or in the emergency department, and 10 (25%) hemodynamically unstable patients with systolic blood pressures <80 mm Hg were rushed to the operating room for EVAR without a preoperative CT scan. The mean time from the presumptive diagnosis of a r-AAA in the emergency department to the operating room for EVAR was 20 minutes (range, 10 to 35 minutes), and the mean operative time from skin incision to closure was 80 minutes (range, 35 to 125 minutes). Seven patients (18%) needed supraceliac aortic occlusion balloon, and six (15%) needed aortouniiliac stent-grafts. The mean blood loss was 455 mL (range, 115 to 1100 mL). Two patients each (5%) developed myocardial infarction, renal failure, and ischemic colitis, seven (18%) developed abdominal compartment syndrome, and seven (18%) died. Over a mean follow-up of 17 months, three patients with endovascular r-AAA repair required four secondary procedures., Conclusions: The early results show that emergent endovascular treatment of hemodynamically stable and unstable patients is associated with a limited mortality of 18% once a standardized protocol is established. There is an increased recognition of emerging complications with an endovascular approach, and a synchrony of disciplines must be developed to initiate a successful program for endovascular treatment of r-AAAs.

Background: Endovascular treatment of ruptured abdominal aortic aneurysms (r-AAAs) has the potential to offer improved outcomes. As our experience with endovascular repair of r-AAA evolved, we recognized that the development of abdominal compartment syndrome (ACS) led to an increase in morbidity and mortality. We therefore reviewed our experience to identify risk factors associated with the development of ACS., Methods: From January 2002 to December 2004, 30 patients underwent emergent endovascular repair of r-AAA by using commercially available stent grafts. All patients who developed ACS underwent emergent laparotomy. Physiological and clinical parameters were analyzed between patients with and without ACS after endovascular r-AAA repair., Results: Over the past 3 years, 30 patients underwent endovascular r-AAA repair, and 6 (20%) patients developed ACS. Patients with ACS had a higher incidence of the need for aortic occlusion balloon (67% vs 12%; P = .01), a markedly longer activated partial thromboplastin time (128 +/- 84 seconds vs 49 +/- 31 seconds; P = .01), a greater need for blood transfusion (8 +/- 2.5 units vs 1.8 +/- 1.7 units; P = .08), and a higher incidence of conversion to aortouni-iliac devices because of ongoing hemodynamic instability and an inability to expeditiously cannulate the contralateral gate (67% vs 8%) when compared with patients without ACS. The mortality was significantly higher in the patients with ACS (67%; 4 of 6) compared with patients without ACS (13%; 3 of 24; P = .01)., Conclusions: ACS is a potential complication of endovascular repair of r-AAA and negatively affects survival. Factors associated with the development of ACS include (1) use of an aortic occlusion balloon, (2) coagulopathy, (3) massive transfusion requirements, and (4) conversion of bifurcated stent grafts into aortouni-iliac devices. We recommend that, after endovascular repair of r-AAA, these patients undergo vigilant monitoring for the development of ACS.

Current options for treating recurrent carotid stenosis (RCS) include standard longitudinal arteriotomy and patch angioplasty with or without carotid endarterectomy (s-PCEA), carotid-carotid bypass, or carotid angioplasty and stent (CAS). Eversion carotid endarterectomy (e-CEA) is an effective procedure for treating primary carotid stenosis, yet it has not been reported for treating RCS. We evaluated the feasibility and outcome of e-CEA for treating of RCS in comparison to s-PCEA. The records of all patients undergoing elective CEA for symptomatic and asymptomatic high-grade RCS from January 1981 to July 2002 were reviewed. Although during the earlier period s-PCEA was performed preferentially, this paradigm changed to e-CEA being the preferred technique for treatment of RCS. During the course of postoperative follow-up when duplex sonography suggested high-grade RCS, the diagnosis was confirmed via arteriography. Data on cranial nerve injury, recurrent stenosis, stroke, and death were prospectively collected into a vascular registry database and analyzed retrospectively, Students' t-test and chi-square analysis were used to compare the group's baseline characteristics and outcomes. Over a 21-year period, 7001 patients underwent primary CEA for symptomatic (n = 2405, 34%) or asymptomatic (n = 4596, 66%) high-grade stenosis via standard (n = 1501, 21%) or eversion (n = 5500, 79%) techniques. Fifteen (25%) patients had 70 to 80% stenosis, 30 (51%) had 81 to 90% stenosis, and 14 (24%) had 91 to 99% stenosis. During this time period, 59 patients presented with symptomatic (n = 18, 31%) or asymptomatic (n = 41, 69%) high-grade RCS and underwent operative repair via s-PCEA (n = 22, 37%) or eversion (n = 37, 63%) techniques. The mean time interval for repeat carotid surgery for RCS was 49 months in the s-PCEA group and 48 months in the e-CEA group. Permanent cranial nerve injuries, stroke, and recurrent restenosis occurred in one (4.5%), one (4.5%), and one (4.5%) of the patients undergoing s-PCEA, respectively. In the e-CEA group, these events occurred in one (27%), none (0%), and one (2.7%) patients, respectively, There were no deaths during the 30-day postoperative period. Eversion CEA is a feasible option for the treatment of many RCSs and can be performed safely with a low rate of cranial nerve injury, recurrent stenosis, stroke, and death.

Objective: Ultrasound scanning is used to detect velocity increases indicative of a bypass stenosis. Subsequent examinations have shown regression of some stenotic lesions. This study examined hemodynamic changes that coincided with stenosis regression., Methods: Duplex ultrasound scans were used to record the peak systolic velocity (PSV) and volume flow from proximal and distal segments of infrainguinal bypasses. Valve remnants or other image defects were also noted. The PSV ratio (Vr) was calculated as the PSV at a stenosis divided by the PSV proximal to the lesion. A stenosis was defined as Vr >/=2.0., Results: An initial ultrasound scan performed 31 +/- 6 days after surgery revealed a stenosis in 68 of 565 bypasses. In six bypasses, the increased PSV (272 +/- 61 cm/s) and Vr (3.4 +/- 1.3) were sustained during the follow-up period of 8 +/- 3 months. In 27 bypasses with a PSV of 335 +/- 63 cm/s and a Vr of 4.0 +/- 1.6, the stenosis was repaired. In 35 bypasses with a PSV of 261 +/- 82 cm/s and Vr of 3.2 +/- 1.2, stenosis regression occurred with no increases in PSV observed on later scans. In this group, proximal bypass flow decreased during the follow-up interval from 247 +/- 130 mL/min to 151 +/- 135 mL/min and distal flow from 180 +/- 102 mL/min to 103 +/- 54 mL/min ( P < .05, paired t test). Ultrasound image abnormalities were noted in 4 bypasses (67%) with persistent stenoses, 14 with repaired stenoses (52%), and 10 with resolved stenoses (29%)., Conclusion: These data indicate early postoperative hyperemia is present in bypasses, demonstrating focal velocity increases. Such velocity increases may be the result of the bypass conduit acting as a flow-limiting lesion until the hyperemia subsides. As the blood flow decreases so does the PSV, giving the appearance of stenosis regression.

The beneficial effects of open surgical abdominal aortic aneurysm (AAA) repair via a left retroperitoneal approach have been established. We compared the short-term outcome of infrarenal AAA repair via an endovascular approach with that of an open retroperitoneal approach. From October 2001 to April 2003, patients with infrarenal AAA >5 cm were offered repair via an endovascular approach (group I) with a variety of industry-made stent grafts or with an open retroperitoneal surgical approach (group II). Data were prospectively collected in the vascular registry and complications were analyzed. Data comparison between the two groups was done by using chi-squared analysis and two-tailed Students t-test. Statistical significance was identified at p < 0.05. Over an 18-month period, 492 patients underwent evaluation for AAA. Of these, 446 patients had infrarenal AAA and underwent either endovascular (group I: n = 175, male 85%, female 15%) or open surgical repair (group II: n = 232, male 74%, female 26%) via a left retroperitoneal approach. Group I patients had a higher incidence of coronary artery disease (66% vs. 35%, p < 0.05), hypertension (74% vs. 43%, p < 0.05), chronic obstructed pulmonary disease (29% vs. 12%, p < 0.05), and diabetes mellitus (20% vs. 7%, p < 0.05), a lower mean amount of intraoperative blood loss (277 cc vs. 1452 cc, p < 0.05), and shorter length of stay in the hospital (1.7 days vs., 7.3 days, p < 0.05). Group I also had fewer complications of myocardial infarction (1.7% vs. 5.2%, p = NS), renal failure (0% vs. 2.6%, p < 0.05), pulmonary failure (1.7% vs. 2.6%, p = NS), ischemic colitis requiring colectomy (0.6% vs. 2.6%, p < 0.05), multisystem organ failure (0% vs. 1.3%, p = NS), and death (0.6% vs. 1.3%, p < 0.05). Despite increased preexisting comorbidities, patients undergoing endovascular aneurysm repair had less morbidity, mortality, and blood loss and a shorter in-hospital length of stay than patients undergoing open surgical aneurysm repair via a left retroperitoneal approach.

Purpose: To prospectively examine the outcomes of excluded abdominal aortic aneurysms (AAA) that continue to expand without evidence of endoleak., Methods: From 1984 to 1998, 1218 patients underwent operative retroperitoneal exclusion of AAA and aortoiliac reconstructions. During the procedure, the aneurysm sac was ligated proximally, as well as distally, which created an ideal in-vivo model of excluded AAA sacs with or without endoleaks. From January 2002 to June 2003, 15 of these patients were identified as having an increase in AAA sac size with or without an endoleak on duplex ultrasonography. These patients were prospectively evaluated by computed tomography and diagnostic arteriography. Patients with a demonstrable endoleak underwent embolization, and the remainder underwent open surgical exploration., Results: Eight patients had arteriographically demonstrated endoleaks that were treated with coil embolization. The remaining 7 patients (6 men; mean age 76 years, range 68-81) without a demonstrable endoleak underwent elective surgical exploration and sac endoaneurysmorrhaphy. The mean time interval between the original surgery and aneurysm sac exploration was 76 months (range 52-92); during this time, the mean aneurysm sac size increased by 2.7 cm (range 1.3-5.2). The mean sac pressure was 53 mmHg, and the sac walls were noticeably thickened, with markedly dilated vasa vasorum. The sac contained yellow, fibrinous material with clear serous fluid (5 patients without any evidence of retrograde flow) or liquefied thrombus with serosanguinous fluid (2 patients with retrograde flow from lumbar arteries). No AAA sacs were pulsatile., Conclusions: Continued expansion of excluded AAA sacs can occur from causes other than a missed endoleak. Exudation of fluid from thickened sac wall and vasa vasorum, as well as local enzymatic activity, might lead to the formation of a sac hygroma. Furthermore, these findings raise questions as to the need for surgical exploration of all patients with an enlarging AAA sac in the setting of low sac pressures and no definable endoleak.

Purpose: Popliteal aneurysms (PAs) often are treated with exclusion and bypass. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries (endoleak), resulting in aneurysm growth and rupture. We used duplex ultrasound scanning for postoperative surveillance more than 2 years after PA repair with exclusion and bypass, to determine the presence of flow and aneurysm growth., Methods: From 1995 to 2001, 23 patients with 26 PAs (mean diameter, 3.2 cm; range, 1.6-5.6 cm) underwent surgical repair and were available for more than 2 years of follow-up. The popliteal artery was ligated proximal and distal to the aneurysm, and autogenous revascularization was performed. All patients who underwent PA endoaneurysmorrhaphy through a posterior approach were excluded from the study. During long-term follow-up, aneurysm sac flow and size were evaluated with duplex ultrasound scanning, computed tomography, or magnetic resonance angiography, and standard angiography. Patients with increased PA size and persistent flow were offered repair through a posterior approach., Results: Over 7 years, 26 PAs (symptomatic, 11; asymptomatic, 15) treated with aneurysm exclusion and bypass were available for more than 2 years of follow-up (mean, 38 months; range, 24-78 months). In the postoperative period 16 PAs (62%) became thrombosed, 10 (38%) had persistent collateral flow through geniculate vessels, 6 (23%) increased in size, and 3 (12%) ruptured; 1 (4%) resulted in limb loss. Operative findings for all ruptured PAs and 3 of 6 PAs with increased sac size that underwent aneurysm sac exploration and endoaneurysmorrhaphy revealed retrograde flow through geniculate vessels, mimicking type II endoleak., Conclusions: These findings question the effectiveness of PA exclusion through proximal or distal ligation and bypass. In addition, retrograde flow into the aneurysm sac (ie, type II endoleak after endovascular abdominal aortic aneurysm repair) may transmit systemic pressure that can result in aneurysm rupture. We recommend PA treatment with aneurysm sac decompression and ligation of geniculate vessels whenever possible and routine postoperative surveillance of the excluded aneurysm sac.

The question remains as to whether patients presenting with aortoiliac occlusive disease (AIOD) or abdominal aortic aneurysms (AAAs) have similar outcomes when concomitant renal artery reconstructions are performed. In this study, we analyzed our experience with simultaneous aortic and renal reconstructions using a retroperitoneal approach. Over a 5-year period, all patients with either AAAs > 5 cm or symptomatic AIOD who were found to have high-grade renal artery stenosis and who underwent aortic reconstructions with concomitant renal revascularization were analyzed through our vascular surgery registry. Morbidity and mortality were quantitatively evaluated. Data were analyzed using the chi-square test. A total of 1,133 patients with AAA (n = 832) and AIOD (n = 301) underwent aortic reconstructions. Two hundred thirty-one patients had 283 concomitant renal revascularizations, including bypass, reimplantation, and endarterectomy, for high-grade (> 70%) renal artery stenosis via a left retroperitoneal approach. The mortality rate of AAA repair with and without renal revascularization was 2.3% (4/178) and 1.5% (10/654), respectively, and that of aortobifemoral bypass for AIOD with and without renal revascularization was 5.7% (3/53) and 2.8% (7/248), respectively. Of the 7 deaths in patients requiring aortic and renal reconstructions, 4 occurred in patients with bilateral renal revascularization. Transient renal insufficiency, ischemic colitis, and cardiopulmonary failure occurred in 5.6%, 2.2%, and 9.6% of patients with AAA repair and in 5.7%, 0%, and 9.4% of patients with AIOD. Two patients developed acute occlusion of their renal bypasses; one was successfully revised, whereas the other led to a nephrectomy. In patients with AAAs, AIOD, and high-grade renal artery stenosis, simultaneous aortic and renal reconstructions can be performed through a retroperitoneal approach with a limited and acceptable mortality. With concomitant renal and aortic procedures, patients with AIOD have a higher mortality when compared with those with AAAs, although this difference is not statistically significant.

Purpose: Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption., Methods: From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg)., Results: There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits., Conclusions: Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.

Since carotid endarterectomy was revitalized following the North American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study, results have improved. However, types of carotid endarterectomy, indications, risk factors, surgical factors, techniques, and other treatment modalities may be associated with outcomes of carotid endarterectomy. The purpose of this study was to identify those factors in a broad-based carotid endarterectomy patient. This study involved review of the data from 3,644 patients undergoing carotid endarterectomy in New York State hospitals. A multivariate statistical model was used to identify significant patient risk factors to examine the association of the process of care and surgical factors, including surgical specialty for outcome of carotid endarterectomy. In-hospital death and stroke rate overall was 1.84%. After adjustment for patient risk factors, specific processes of care, such as eversion endarterectomy, protamine, heparin, or shunt, were associated with lower adverse outcomes relative to patients undergoing carotid endarterectomy without these processes. Similarly, patients undergoing carotid endarterectomy by vascular surgeons had lower adverse outcomes compared to neurosurgeons and general surgeons. This retrospective review showed that processes of care and surgical specialty were significant factors that contributed to outcomes following carotid endarterectomy.

Technological advancements have lead to dramatic improvements in stentgraft device design resulting in more trackable delivery systems and transrenal uncovered stents and barbs for better fixation. Transrenal bare-stents may limit stentgraft migration, particularly in patients with short or flared proximal aortic necks. However, potential disadvantages might be in worsening renal function, particularly in patients with preexisting renal insufficiency. We retrospectively analyzed our recent 7 year experience of patients undergoing endovascular aneurysm repair (EVAR) using a variety of stentgrafts with and without transrenal bare-stent fixation. Patients were divided into 2 groups; infrarenal fixation (IRF) vs transrenal fixation (TRF), or patients with preoperative serum Cr values that were normal (= or <1.5 mg/dl) vs slightly elevated (1.6-2 mg/dl), vs markedly elevated (2.1- 3.5 mg/dl). The exclusion criteria included patients with chronic renal insufficiency (CRI) on hemodialysis, and preoperative high-grade renal artery stenoses requiring angioplasty and stenting. Of 705 patients that underwent EVAR, 496 (IRF: 385 [78%], and TRF: 111 [22%]) were available with routine evaluations of serum Cr and CT scans. Preexisting comorbidities, mean procedure contrast volume, and postprocedure follow-up were similar in both groups. In the immediate postoperative period, mean serum Cr did not change significantly in either the IRF group (1.3+/-0.7 mg/dl to 1.2+/-0.9 mg/dl) or the TRF group (1.3+/-0.5 mg/dl to 1.3+/-0.6 mg/dl). Mean serum Cr did, however, significantly increase over longer follow-up in both groups: 1.4+/-0.8 mg/dl for IRF (P<0.03), and 1.5 +/- 0.8 mg/dl for TRF (P<0.01). Cr clearance was similarly unchanged in the immediate postoperative period (58+/-23 to 61+/-25 ml/min/1.73 m2 for IRF group, 53+/-17 to 55+/-17 ml/min/1.73 m2 for TRF group), but was significantly decreased in longer follow-up (53+/-23 ml/min/1.73 m2 for IRF, p<0.02: and 48+/-16 ml/min/1.73 m2 for TRF, P<0.01). There were no significant differences in serum Cr increase (p=0.19) or Cr clearance decrease (p=0.68) between the IRF and TRF groups. Small renal infarcts were noted in 6 patients (1.6%) in the IRF group, and in 8 patients (7%) in the TRF group (p=0.37). Of patients with normal preoperative renal function, renal dysfunction developed in 7.7% of IRF group and 6.1% of TRF group (p=0.76). In patients with preexisting CRI, renal dysfunction developed in 18.2% of IRF group, and 17.1% of TRF group (p=0.95). Eight patients with postoperative renal dysfunction, 5 (1.3%) from IRF group and 3 (2.7%) from TRF group subsequently required hemodialysis, and this difference was not statistically significant (p=0.91). We also analyzed 200 consecutive patients undergoing EVAR with intra-arterial contrast agents with and without preexisting CRI not on dialysis. The groups were identified on the basis of preprocedure serum Cr: group 1 (n=108), Cr less than 1.5 mg/dL (normal range); group 2 (n=65), Cr 1.5 to 2.0 mg/dL; group 3 (n=27), Cr 2.1 to 3.5 mg/dL. Routine precautions in patients with CRI included preoperative intravenous hydration with 2 L of normal saline solution, discontinuation of all nephrotoxic drugs, intraoperative administration of mannitol (0.5 g/kg intravenously), and use of nonionic, low osmolar intra-arterial contrast agent (Omnipaque 350). One-hundred and eight patients had normal renal function (group 1), and 92 patients had preexisting CRI with baseline Cr 1.5 to 2.0 mg/dL (group 2, n=65) or 2.1 to 3.5 mg/dL (group 3, n=27). Comorbid conditions included coronary artery disease (group 1, 51%; group 2, 49%; group 3, 59%), hypertension (group 1, 39%; group 2, 46%; group 3, 52%), and diabetes mellitus (group 1, 25%; group 2, 35%; group 3, 48%). In groups 1, 2, and 3, the mean volume of low osmolar contrast agent used was 210 cc, 160 cc, 130 cc, respectively; hemodynamic instability developed in 3, 1, and 1 patient, respectively. The incidence of postoperative complications between the 3 study groups was not statistically different. In grications between the 3 study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in 3 patients (2.7%), 2 of whom (1.9%) required temporary hemodialysis and 1 (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in 2 patients (3.1%); both patients (3.1%) required temporary hemodialysis, and 1 patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in 2 patients (7.4%); 1 patient (3.7%) required temporary hemodialysis, and 1 patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (p<0.05), and larger contrast volume was associated with an increase in serum Cr (p<0.05) during the postoperative period. Following EVAR renal function declines slightly with both IRF and TRF. Our data show no overall difference between patients with IRF and TRF with respect to infarcts, decline in renal function, or onset of dialysis. There were a slightly greater number of renal infarcts in the TRF group, but these infarcts were clinically inconsequential. In patients with CRI, EVAR with intra-arterial radiographic contrast agents is believed to impair renal function, and CRI is considered a relative contraindication to the procedure. Results of our investigation indicate that risk for worsening renal insufficiency, dialysis, and death is only slightly and not significantly greater in patients with CRI compared with patients with normal renal function. With appropriate precautions of avoiding perioperative hypotension and limiting the volume of nonionic contrast agents, CRI need not be a contraindication for EVAR with intra-arterial contrast agents.

Purpose: Emergent repair of ruptured abdominal aortic aneurysms (rAAAs) is associated with high perioperative morbidity and mortality. One of the significant complications of this surgery is bowel ischemia. Reports detail mortality as high as 80% when this condition is realized. The objective of this project was to determine both the incidence and the effect of mandatory postoperative colonoscopy on outcome of colon ischemia after rAAA., Methods: From July 1995 to September 2002 all patients with an rAAA who underwent emergent aortic reconstruction were included in this review. All colonoscopies were performed within 48 hours, ischemia was graded consistently, and treatment was initiated per protocol based on grade of ischemia. Patients with grades I and II ischemia were followed up with medical management and repeat colonoscopy. All patients with grade III ischemia underwent bowel resection. Preoperative, intraoperative, and postoperative variables were collected to assess possible independent risk factors for and predictors of bowel ischemia., Results: Eighty-eight patients underwent emergent aortic reconstruction because of rAAA in the study period. Their mean age was 73 years, and 64 patients (72%) were men. Operative mortality was 42%. Eighteen percent of patients died within 24 hours, and 24% died between 1 and 30 days after surgery. Colonoscopy was performed in 62 of 72 patients who survived more than 24 hours. Bowel ischemia was documented in 26 of the 72 patients (36%). Of these, 16 patients had grade I or grade II ischemia at both initial and repeat endoscopy. Nine patients underwent exploratory laparotomy with bowel resection because of grade III ischemia; two procedures were performed because of worsening ischemia discovered at repeat colonoscopy. In patients with colonoscopic findings of bowel ischemia the mortality rate was 50% (13 of 26 patients). In those with grade III necrosis who underwent resection the mortality rate was 55%. Elevated lactate levels, immature white blood cells, and increased fluid sequestration were all variables associated with the occurrence of colon ischemia., Conclusions: Bowel ischemia is a frequent postoperative complication (42%) of repaired rAAA. Performing mandatory surveillance colonoscopy in these patients may be associated with a decrease in overall mortality and improved survival in patients with transmural bowel necrosis with no comorbid condition.

Purpose: Carotid endarterectomy (CEA) after acute stroke is generally delayed 6 to 8 weeks because of fear of stroke progression. This delay can result in an interval stroke rate of 9% to 15%. We analyzed our results with CEA performed within 1 to 4 weeks of stroke., Methods: Records for all patients undergoing CEA after stroke between 1980 and 2001 were analyzed. Perioperative evaluation included carotid duplex scanning or angiography, and head computed tomography or magnetic resonance imaging. All patients with nonworsening neurologic status, additional brain territory at risk for recurrent stroke, and severe ipsilateral carotid stenosis underwent CEA. Patients were grouped according to time of CEA after stroke: group 1, first week; group 2, second week; group 3, third week; group 4, fourth week. Statistical analysis was performed with the chi(2) test, logistic regression, and analysis of variance., Results: Two hundred twenty-eight patients underwent CEA within 1 to 4 weeks of stroke. Perioperative permanent neurologic deficits occurred in 2.8% of patients in group 1 (72 procedures), 3.4% of patients in group 2 (59 procedures), 3.4% of patients in group 3 (29 procedures), and 2.6% of patients in group 4 (78 procedures). There was no relationship between location or size of preoperative infarct and time of surgery. Only preoperative infarct size correlated with probability of neurologic deficit after CEA (P <.05)., Conclusion: Incidence of postoperative stroke exacerbation is similar at all intervals. The results are within acceptable limits for treatment of symptomatic carotid stenosis. CEA may be performed within 1 month of stroke with similar results at all intervals during this period.

Objective: Patients with end-stage renal failure and upper-extremity arterial occlusive disease sometimes have painful digital ulceration. We evaluated the efficacy of distal bypass grafting from the brachial artery for limb salvage in this setting., Methods: All patients with end-stage renal disease with painful digital ulceration or gangrene of the hand seen from 1992 to 2002 were evaluated with clinical examination and noninvasive studies. Those with evidence of occlusive disease underwent conventional angiography. Individuals with forearm occlusive disease underwent bypass grafting, from the brachial artery to either the distal radial artery or ulnar artery at the level of the wrist or proximal hand. Follow-up was scheduled at regular intervals, and included duplex scanning. Limb salvage and bypass graft patency were determined with life table analysis., Results: Over 10 years, 18 forearm bypass procedures were performed in 15 patients. The outflow artery was the radial artery in 15 procedures and the ulnar artery in 3 procedures. Bypass conduit was autogenous in all patients. No patient had a functioning arteriovenous fistula at bypass grafting; six limbs had previously occluded fistulas. Two bypass grafts (11%) occluded in the early postoperative period, with resultant progression of gangrene. In the remaining 16 grafts patency was maintained (mean follow-up, 18 months), with pain control and tissue healing., Conclusion: Treatment in patients with renal failure with upper extremity occlusive disease may be facilitated with brachiodistal bypass grafting. Pain control and reversal of progression of hand necrosis can be achieved.

Exposure of the abdominal aorta through the left retroperitoneum is a well-accepted technique. Unfortunately, splenic injury is a complication of this approach that rarely occurs through a mid-line transabdominal incision. In this series we evaluate the occurrence of splenic injury during left retroperitoneal aortic surgery. The records of all patients undergoing abdominal aortic reconstruction via the left retroperitoneal approach were reviewed from 1988 to 2001. Indications included either abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD). Thoracoabdominal aneurysms and visceral aortic reconstructions were excluded. Those patients that required splenectomy for splenic injury were stratified and analyzed for demographics, indications for operation, and other complications. Chi-square analysis was used to determine statistical significance. Over the 13-year study period, 2889 aortic reconstructions were performed. These consisted of 1773 elective AAA repairs, 357 ruptured or symptomatic AAA repairs, and 759 aortofemoral bypasses for AIOD. Splenectomies were performed after aortic repair in 21 (0.7%) patients. Breakdown by indication totaled 11/1773 (0.6%) for elective AAA repair, 7/357 (2.0%) for rupture or symptomatic AAA repair, and 3/759 (0.4%) for AIOD ( p < 0.05). Mortality for patients undergoing elective AAA without splenectomy was 1.9% (34/1762) and with splenectomy was 9.1% (1/11), while it was 3.2% (24/756) for AIOD patients without splenectomy and 14% (1/7) for AIOD patients with splenectomy (all p = NS). Splenic injury can occur in elective and emergent aortic reconstructions performed through the left retroperitoneum. The surgeon should be prepared for splenectomy whenever intraperitoneal blood or hemodynamic instability is identified. Evaluation of the spleen prior to flank closure may be prudent.

Purpose: Several investigators have suggested a dismal prognosis of ruptured abdominal aortic aneurysm (rAAA) repair in the elderly. The purpose of this study is to evaluate the morbidity and mortality of rAAA repair in octogenarians and compare it to that of a younger population., Methods: From 1980 to 2000, all patients undergoing emergent rAAA repair were divided into two groups based on their age; Group I: age <80, Group II: > or =80 years. Outcomes were evaluated based on a Chi-square test and a P-value <0.05 indicated statistical significance., Results: Over a 20-year period, 323 patients underwent rAAA repair through a left retroperitoneal (74%) or standard transperitoneal (26%) approach. In Group I (age <80 years) and II (> or =80 years), the overall 30-day mortality was 25 and 41% (P<0.05), respectively. Furthermore, the elderly population had a higher incidence of death due to myocardial infarction (15 vs. 7%), as well as non-fatal cardiac and cerebrovascular events (17 vs. 4%) when compared to the younger patients., Conclusion: Although the elderly patients have an increased risk of having cardiac and cerebrovascular events in the postoperative period, the treatment of rAAAs in these patients should not be any different than that of a younger population. The left retroperitoneal approach is feasible and beneficial for rAAA repair and is associated with a limited morbidity and mortality.

Purpose: Recurrent carotid stenosis following standard longitudinal carotid endarterectomy (s- CEA), with and without patch angioplasty, effects the durability of the procedure and can lead to reintervention. The purpose of this study is to evaluate the incidence of restenosis following eversion carotid endarterectomy (e-CEA) in women., Methods: The records of all patients undergoing elective carotid endarterectomy (CEA) for symptomatic and asymptomatic high-grade carotid stenosis over a 5-year period from July 1994 to June 1999 were reviewed. Eversion endarterectomy was performed preferentially under regional anesthesia in awake patients. Postoperatively, patients were routinely evaluated by duplex scans at 3 months, 6 months, 12 months, and yearly thereafter. Hemodynamically significant restenosis (>70%) via duplex scans was confirmed by standard or magnetic resonance angiography. Student's t-test and Chi square analysis were used to assess statistical significance and assumed for P<0.05., Results: Over this 5-year period, 3429 eversion carotid endarterectomies were done for symptomatic (female: 375, male: 573) and asymptomatic (female: 1091, male: 1390) high grade carotid stenosis. In the postoperative period 18 (0.9%) male and 12 (0.8%) female patients developed a permanent stroke (P = NS). Operative mortality was 0.6% (n = 12) in males and 0.5% (n = 8) in females (P = NS). Cranial nerve injuries, wound infections, and neck hematoma occurred in 7 (0.4%), 2 (0.1%), and 26 (1.3%) male and in 3 (0.2%), 3 (0.2%), and 15 (1.0%) female patients, respectively. Recurrent carotid stenosis greater than 70% via duplex scan (PSV >125 cm/s and EDV >100 cm/s) developed in 12 (1.0%) males and 15 (1.5%) females (P = NS)., Conclusion: The eversion technique for CEA requires both the transection and anastomosis of the internal carotid artery at the carotid bulb, and appears to result in a low incidence of restenosis in women. This is a straightforward technique and obviates the need for primary closure of distal smaller caliber internal carotid artery that can lead to narrowing, and the use of patch closure that has its attendant risks.

Purpose: Nonoperative treatment of recent internal carotid artery (ICA) occlusion is associated with increased recurrent stroke rates. We analyzed our results of carotid endarterectomy (CEA) for treatment of symptomatic recent ICA occlusion to evaluate its feasibility, safety, and outcomes., Methods: From 1990 to 2002, all patients with transient ischemic attack (TIA), amaurosis fugax, and minor stroke underwent duplex ultrasound (US) scanning and arteriography to confirm the diagnosis of ICA occlusion. Within 2 weeks of symptom onset, patients underwent operative exploration with attempted CEA. ICA occlusion was detected at preoperative angiography and confirmed at surgery. Patients with extensive ICA plaque not amenable to endarterectomy underwent external CEA with ICA ligation., Results: Over 12 years, 87 patients with symptomatic ICA occlusion underwent 90 operations for ICA exploration. In 30 patients (18 men, 12 women) with TIA (45%), amaurosis fugax (19%), or minor stroke (36%), CEA to treat ICA occlusion was technically successful. There was 1 postoperative stroke, 2 asymptomatic internal carotid occlusions, and no restenoses (mean follow-up, 26 months; range, 1-93 months). In 57 patients (37 men, 20 women) with TIA (41%), amaurosis fugax (27%), or stroke (32%) in whom CEA was unsuccessful, external CEA was performed. In this group there were no postoperative strokes, 2 asymptomatic external carotid artery occlusions, and 1 restenosis (>70%) (mean follow-up, 22 months; range, 1-73 months). There were no late strokes in either group., Conclusion: Operative exploration and endarterectomy to treat symptomatic ICA occlusion is feasible and safe. Patients with symptomatic ICA occlusion should be considered candidates for CEA.

Purpose: Reconstruction of a diseased common carotid artery may necessitate direct repair via aortic artery-based revascularization. However, carotid-carotid artery crossover grafting is an alternative extra-anatomic option that obviates the need for median sternotomy. We analyzed our results with carotid-carotid artery crossover bypass surgery., Methods: Data were analyzed for all patients undergoing carotid-carotid crossover bypass surgery from 1995 to 2000. Data on patient demographics, indications for surgery, perioperative morbidity and mortality, and graft patency were retrieved from a vascular surgery data base and hospital records. Stroke-free survival and graft patency were determined with life table methods., Results: Over 5 years, 24 carotid-carotid artery crossover bypass procedures were performed to treat both symptomatic (n = 19, 79%) and asymptomatic (n = 5, 17%) disease. Nine procedures (38%) were performed in men, 3 (13%) in patients with diabetes, 12 (50%) in active smokers, and 2 in patients with a history of Takayasu arteritis. Patient mean age was 63 years (range, 38-79 years). Twenty-three patients (96%) received polytetrafluoroethylene conduit grafts, and the remaining patients received vein grafts. Ten (42%) patients underwent concomitant endarterectomy. There were no perioperative deaths. One patient (4%) had asymptomatic early occlusion, one had transient neurologic deficit (4%), one (4%) required additional surgery because of bleeding, and one (4%) had a perioperative cerebrovascular accident (stroke). Three (17%) asymptomatic late occlusions were identified at 11, 57, and 64 months, respectively. Mean follow-up was 30 months (range, 1-70 months). Primary patency was 88%, and secondary patency was 92% at 3 years. Stroke-free survival was 94% at 4 years., Conclusion: Carotid-carotid artery crossover bypass surgery is a safe and durable procedure. Its use precludes the need for median sternotomy and provides acceptable stroke-free survival.

Objective: Few will debate that infrainguinal arterial reconstruction increases limb salvage. However, numerous reports describe a difference in results in coronary and peripheral arterial reconstructions between men and women. In this study, we analyze the outcome of infrainguinal bypasses performed over 30 years and stratify the results by gender., Methods: We reviewed our vascular registry from 1968 to 1999 for all infrainguinal arterial reconstructions. Demographics, indications, and adverse outcomes were analyzed. Patency, limb salvage, and survival rates were determined with life-table analysis. The chi2, log-rank, and Student t tests were used to determine statistical significance., Results: Five thousand eight hundred eighty procedures were performed, with 2161 in women (37%). Women were significantly older (71 versus 66 years), more often diabetic (53% versus 50%), and less often smokers (27% versus 44%) and more often had surgery for limb salvage (89.8% versus 81.0%). Mortality, complications, and need for revision did not differ. Primary patency rate was 44% versus 47%, secondary patency rate was 55% versus 58%, and survival rate was 39% versus 34% in men and women, respectively, at 10 years (all P >.05). Limb salvage rate in women exceeded that in men (93% versus 88%) at 10 years. Subgroup analysis by conduit also revealed no difference in patency., Conclusion: Infrainguinal arterial reconstruction can be performed safely with comparable results in women and men. Although women may present older and more often for limb salvage, outcomes do not appear to be adversely affected.

Coronary subclavian steal syndrome (CSS) results from proximal subclavian artery occlusive disease causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass leading to myocardial ischemia. Although percutaneous transluminal angioplasty and stent (PTAS) for subclavian lesions has been successful, it is not always feasible. In this study, the results of carotid subclavian bypass (CSB) for symptomatic CSS due to subclavian occlusion and stenosis not amenable to PTAS were analyzed. The records of patients undergoing CSB for CSS between 1991 and 2001 were reviewed. Patients with lesions not amenable to angioplasty or stent were selected for CSB. Degree of preoperative myocardial ischemia was stratified according to New York Heart Association classification. Graft patency was analyzed by life-table methods. Our results showed that CSB for treatment of symptomatic CSS can be performed safely with excellent mid-term durability. In the setting of proximal subclavian artery disease not amenable to PTAS, CSB provides an acceptable means of treatment for symptomatic CSS.

Objectives: Carotid endarterectomy (CEA) has a positive effect on stroke free survival in patients with either symptomatic or asymptomatic severe carotid bifurcation stenosis. However, most trials have excluded octogenarians. In addition, concerns have arisen regarding the benefits of CEA in the elderly population, especially in women. In this study, we performed an outcome analysis in patients undergoing CEA comparing those eighty and older to their younger counterparts. Additionally, we evaluated the elderly group based on gender., Methods: Over the past 10 years, all patients undergoing CEA for asymptomatic and symptomatic carotid disease have been entered into our vascular surgery registry. Demographics, indications for operative intervention, outcomes and survival of patients who had undergone CEA were reviewed. Procedures were preferentially performed under regional anesthesia with selective shunting. Chi square analysis was used to assess significance and assumed for P<0.05., Results: Over the last 10 years, 125 carotid endarterectomies were performed in 125 patients eighty years of age or older. Fifty-six were male and 69 were female. Mean age was 83 (range: 80-97). Asymptomatic disease was identified in 28 of the male patients (50%) and 44 of the female patients (64%). There were no deaths and a permanent neurological deficit occurred in one female patient. There was no difference in thirty-day morbidity or mortality in female patients compared to males., Conclusions: These observations suggest that CEA can be safely performed in selected elderly patients with asymptomatic or symptomatic carotid artery stenosis. Furthermore, women over 80 may expect equally optimistic results as their male counterparts.

Purpose: Although infrequent, reconstruction of the internal carotid artery due to recurrent or extensive disease, tumor, or difficulty in completing the endarterectomy, may be necessary. Few studies evaluate the type of material used as conduit in regard to outcome. In this report we detail our results using both prosthetic and vein bypass of the internal carotid artery for atherosclerotic bifurcation stenosis., Methods and Materials: All patients undergoing carotid artery reconstruction over the last 10 years were retrieved from our vascular registry. Those patients requiring bypass of the internal carotid artery were included. Demographics, indication, complications, and long term follow-up were reviewed. Chi square and log rank analysis was used to compare bypass with PTFE to those with vein as conduit., Results: Over the last 10 years, 44 reconstructions of the internal carotid artery were performed in 41 patients. Twenty-two procedures used prosthetic and 22 used vein. Asymptomatic carotid artery occlusive disease was identified in 14 of the 22 procedures with PTFE, and in 10 of 22 patients with vein. There was no operative mortality in the prosthetic group, and one patient died of a stroke (4.5%) in the vein graft group. There were no strokes or occlusions in the PTFE group. Two permanent neurologic deficits (9%) and one occlusion occurred in the vein bypass group. In follow-up, there have been no late occlusions in the PTFE group, and three in the vein group., Conclusion: While endarterectomy is the procedure of choice in carotid bifurcation stenosis, internal carotid artery bypass can be performed with reasonable outcomes whenever necessary. Prosthetic reconstruction of the internal carotid artery had acceptable results that was comparable to vein graft reconstruction.

Objective: Women undergoing coronary artery bypass grafting (CABG) have higher mortality and morbidity in numerous studies. Although controversial, similar results have been seen in women undergoing carotid endarterectomy. We examined the results of combined eversion CEA/CABG by one group to analyze if the outcome is different between men and women in this setting., Method: The records of all patients undergoing combined eversion CEA/CABG were reviewed from our vascular registry between January 1992 and January 2001. Indications, demographics, morbidity, and mortality were retrieved. These results were compared on the basis of gender as well as to patients undergoing CEA alone. Significance was assessed using Theta(2) analysis., Results: There were 563 combined eversion CEA/CABG procedures performed over the 9-year study period: 324 in men and 239 in women. Asymptomatic >70% stenosis was seen in 275 (85%) male patients and 215 (90%) female patients (P = not significant [NS]). Stroke was found in four men vs three women (1.2% vs 1.3%, P = NS), whereas death occurred in 13 men and five women (4.0% vs 2.1%, P = NS). Thirty-day stroke/mortality was 4.9% in men vs 3.3% in women (P = NS). During the same period, patients undergoing CEA alone were subject to a stroke-mortality rate of 1.6% in men and 1.2% in women (P = NS)., Conclusion: This series demonstrated no difference in outcome among patients undergoing combined eversion CEA/CABG procedures on the basis of gender. Although the results demonstrate a significantly higher mortality and morbidity in patients undergoing combined procedures when compared to carotid surgery alone, the combined procedures can be performed safely in both genders. The large number of asymptomatic patients in both the combined and solo procedures may have positively influenced these results.

Objective: Autogenous vein is the conduit of choice in patients presenting for infrainguinal arterial reconstruction. Venous conduit may be limited because of inadequacy or prior utilization. Our group and others use prosthetics to maximize limb salvage with moderate results. However, in cases where patients present with an isolated popliteal segment that may extend below the knee, we have performed prosthetic bypasses to this above-knee segment and then used a venous reconstruction from the native arterial circulation to a more distal outflow tract. In this report, we will analyze our results using this type of reconstruction in patients who present for limb salvage with no all-autogenous option., Method: From 1992 to 2000, 27 patients presented for limb salvage with an isolated popliteal artery and inadequate vein for continuous bypass. There were 106 patients in this period without an isolated popliteal segment or adequate vein who underwent prosthetic bypass with distal vein cuff or arteriovenous fistula. The vascular registry and patient charts were reviewed for indication, demographics, and type of composite reconstruction. Outcomes were calculated with use of life table methods and compared by log rank analysis., Results: Demographics revealed 16 (59%) men, 16 (59%) patients with diabetes, and 4 (15%) smokers with a mean age of 71 years (range, 51-87 years). The venous reconstructions had the inflow taken from the distal native popliteal artery in 26 (above knee in 8 and below knee in 18) and the peroneal artery in one. The outflow involved the below-knee popliteal in one (4%), a tibial in 23 (85%), and the dorsalis pedis artery in 3 (11%). Morbidity included bleeding (4%), wound infection (4%), and limb loss (4%). Mortality occurred in one patient (4%), and no revisions were required in follow-up. Six late failures were identified, one of which resulted in amputation. Primary patency and limb salvage were 80% and 88% at 1 year, respectively. For comparison, our results using prosthetic with vein cuff had a 1-year primary patency of 52% and limb salvage of 92% (P = NS), whereas prosthetic with an arteriovenous fistula was 73% and 84%, respectively (P = NS)., Conclusions: Composite sequential reconstruction using an isolated popliteal segment as inflow for the distal reconstruction is an acceptable option in patients presenting for limb salvage reconstruction with limited venous conduit. This type of reconstruction, when available, may be a better option than pure prosthetic with or without a vein cuff or arteriovenous fistula.

Purpose: Infrainguinal arterial reconstruction with vein as the conduit has been regarded as the gold standard within the past two decades. However, as many as 20% of patients undergoing these bypass grafting procedures may need secondary interventions for continued patency. Once these reconstructions have been altered, there is concern about the continued patency of these types of revascularizations. In this study, we evaluated the long-term patency of venous reconstructions that had been revised, compared them with those bypass grafting procedures that did not require any intervention, and analyzed long-term outcome., Methods: In the past 15 years, 3944 infrainguinal arterial reconstructions were completed with vein as the conduit. A total of 2780 were performed with the vein in situ, and 1164 were performed by using excised vein in a single piece or spliced configuration. Indication, risk factors, and patient demographics were evaluated. Grafts were stratified into revised and unrevised, in situ and excised; excised vein was then stratified into spliced and non-spliced. All grafts were followed with duplex ultrasound scans performed at 3, 6, and 12 months in the first year and every 6 months thereafter. Statistical analysis was performed by using Gehan's generalized Wilcoxon test., Results: Demographics and indications were similar between groups. Nine percent of all excised veins required some revision, compared with 10% of all in situ reconstructions. When the excised veins were further stratified, 6% of single-piece venous conduits were revised, as opposed to 14% of reconstructions with spliced venous reconstruction. The 5-year patency rates were 67% for revised reconstructions and 78% for unrevised reconstructions (P <.0001). The 5-year patency rate of unrevised in situ bypass grafts was 81%, as compared with 69% for revised in situ reconstruction (P <.0001), and the 5-year patency rate for unrevised excised veins was 68%, with revised excised vein having a 5-year patency rate of 59% (P = not significant)., Conclusion: Venous conduits that require revision have a significantly lower long-term patency rate than those that were unrevised. Grafts that require revision may be best suited for aggressive surveillance protocol to maximize long-term patency.

Objective: Single-piece vein remains the conduit of choice in patients who need bypass grafting for limb salvage. When this option is not available, two of the remaining options are prosthetic bypass graft or several segments of vein spliced together. In this study, we compare spliced vein bypass grafting versus polytetrafluoroethylene grafting with a distal vein cuff in patients with limb-threatening ischemia., Methods: Between 1996 and 2000, 39 bypass grafting procedures in 36 patients were performed for limb-threatening ischemia. These procedures were prospectively randomized to either spliced vein bypass grafting (spliced group, 19 bypass grafts) or polytetrafluoroethylene grafting with a distal vein cuff (cuff group, 20 bypass grafts). All the patients in the cuff group underwent anticoagulation therapy with warfarin sodium after surgery. The inclusion criteria included: no single-piece vein option for bypass grafting, adequate vein for splice, no composite sequential option, and limb-threatening ischemia. The demographics were similar between the two groups., Results: The primary patency rate at 2 years was 44% and 49% for the spliced and cuff groups, respectively. In the spliced group, seven of 19 bypass grafts underwent revision in the follow-up period, and two of 20 cuffed bypass grafts were successfully revised. The secondary patency rate was 87% and 59% (P <.05), with limb salvage rates of 94% and 85% for spliced and cuff groups, respectively. Four patients in the spliced vein group needed reoperation for wound complications related to vein harvest. One polytetrafluoroethylene graft needed removal for infection. Two early mortalities occurred in the spliced group, one from myocardial infarction and one from stroke. The overall survival rate at 2 years between the two groups was 67% and 100% for the spliced and cuff groups, respectively (P <.05)., Conclusion: Although this is a preliminary report, it appears that both spliced vein bypass grafting and polytetrafluoroethylene bypass grafting with a distal vein cuff produce acceptable limb salvage rates. The secondary patency rate for spliced vein is better, but these bypass grafts more often need revision or reoperation for wound complications.

Originally thought to be a disadvantaged outflow source, the dorsalis pedis artery is associated with excellent patency and limb salvage in the diabetic population. The aim of this study was to demonstrate that the dorsalis pedis artery is as durable in nondiabetics as in their diabetic counterparts. During a 21-year period from 1979 to 1999, 299 long lower limb bypasses to the dorsalis pedis artery were performed at our institution. Patient data and outcomes were reviewed from the vascular registry. Statistical analysis and patency rates were compared using chi-squared and log-rank analysis. This study confirms that the dorsalis pedis can be used as an outflow source with durability that is comparable in both diabetics and nondiabetics. No significant difference exists in morbidity, mortality and patency rates. In the nondiabetic, when the dorsalis pedis is the only patent distal vessel, amputation can be avoided if one considers this a suitable option as an outflow source.

Objective: Renal artery stenosis has been classically addressed with saphenous vein bypass graft or transaortic endarterectomy performed either primarily or in combination with an aortic procedure. In this series, we report the outcome of our 12-year experience with renal artery reconstruction using prosthetic conduit., Methods: Patients undergoing renal artery bypass grafting from 1987 to 1999 were identified. Demographics, indications, concurrent operations, complications, and patency were analyzed. Patients underwent postoperative duplex scan with subsequent ultrasound scans at 6-month intervals., Results: There were 489 procedures performed in 414 patients with indications: high-grade renal artery stenosis in combination with abdominal aortic aneurysm repair or symptomatic aortoiliac occlusive disease (309 [63%]), renovascular hypertension (118 [24%]), and renal salvage (20 [4%]). Indications for the remainder included trauma, renal artery aneurysm, or an infected aortic graft. Inflow was aorta or aortic graft in 95% of patients with the remainder taken from the iliac or visceral vessels. The retroperitoneal approach was used in 97.8%. Nonfatal complications occurred in 11.4% with a 1.4% early and 4.8% late occlusion rate. Renal function worsened in 3.1% of all patients. Secondary patency at 1 and 5 years was 98% and 96%, respectively., Conclusion: Renal artery reconstruction with prosthetic conduit has an acceptable and durable result whether used for primary renal artery reconstruction or concomitant reconstruction with aortic procedures.

Objective: Symptomatic arterial disease of the upper extremity is an uncommon problem. In this study, we evaluate our results with brachial artery reconstruction in patients who present with symptomatic atherosclerotic occlusive disease and compare this cohort's demographics with a similar group with lower extremity ischemia., Methods: From 1986 to 1998, all patients presenting for upper extremity revascularization with chronic ischemia were prospectively entered into a vascular registry. Demographics, indications, outcomes, and patency were recorded. Patients presenting with embolus, pseudoaneurysm, or trauma were excluded. The Fisher exact and Student t tests were used to assess significance., Results: Fifty-one (83%) bypass grafts were performed with autogenous conduit and the remainder with polytetrafluoroethylene. Indications included 18 (30%) patients with exertional arm pain, 35 (57%) with rest pain, and 8 (13%) with tissue loss. Twenty-five (45%) patients were male, 8 (14%) had diabetes, and 30 (54%) were smokers. The mean age was 58 years (range, 33-93). The operative mortality rate was 1.8%, and follow-up ranged from 1 to 140 months. Eight occlusions were identified, with six occurring early. Five of these were in women with a smoking history. Only one of the 26 reconstructions that did not cross a joint occluded, whereas bypass grafts that did cross a joint occluded more frequently. No other major complications were recognized., Conclusion: Arm revascularization for ischemia can be performed with reasonable mortality and morbidity rates. These patients may represent a different subgroup of atherosclerotic disease than those with lower extremity involvement: they are more commonly women and smokers and less likely to be diabetic.

Vascular care, diagnosis, and intervention can be very complex. Multiple specialists commonly are involved in dealing with patients with systemic atherosclerotic disease. Although each specialist may provide state-of-the-art care with good result, it would be advantageous to minimize duplication of effort and thereby improve cost efficiency. Patients still could reap the benefit of all these disciplines if evaluated for their vascular complaint in a coordinated system. In doing so, atherosclerosis prevention with risk factor modification, as well as diagnosis and therapy for the presenting problem all can be simultaneously managed. This is the concept that has motivated groups such as our own to form a comprehensive vascular center. We describe our experience with establishing a vascular center and outline its benefits and limitations., (Copyright 2001 by W.B. Saunders Company)

Purpose: In an effort to minimize long-term disability related to effort thrombosis of the subclavian vein, selected patients were treated with thrombolysis, thoracic inlet decompression, percutaneous transluminal angioplasty (PTA), and subclavian vein stenting. We evaluated the long-term outcomes of patients treated with this algorithm., Methods: Between 1994 and 2000, 23 patients were evaluated with effort thrombosis of the subclavian vein. Thrombolysis was instituted on an average of 9.4 days (range, 1-30 days) after initial onset of symptoms. Average time to clot lysis was 34 hours (range, 12-72 hours). After immediate supraclavicular thoracic inlet decompression, all patients underwent PTA. Fourteen patients with residual vein stenosis (>50%) after PTA underwent stenting of the subclavian vein. Complications in this series included three wound hematomas that required drainage in two patients and one subpleural hematoma that required thoracotomy for decompression., Results: All patients who underwent PTA are patent, with a mean follow-up of 4 years (range, 2-6 years). In the veins treated with stents, 9 of 14 veins are patent, with a mean follow-up of 3.5 years (range, 1-6 years). Two veins had early occlusions (2 days); two veins occluded at 1 year; and seven veins occluded at 3 years. Three of the patients (including those patients who experienced the early failed procedures) were later identified with factor V Leiden. Early failures also had clot extending into the brachial vein., Conclusion: Patients with short-segment venous strictures after successful lysis and thoracic outlet decompression may safely be treated with subclavian venous stents and can expect long-term patency.

Patients with severely diseased or occluded infrageniculate arteries, limited runoff, and tissue loss may often present for primary amputation. In this study, we review our experience with plantar artery revascularization when no other bypass options are feasible. All patients requiring infrainguinal bypass to the plantar artery level over the last 3 years were prospectively entered into our vascular surgery database. Indications, demographics, length of stay (LOS), outcome, and patency were reviewed. Our results showed that plantar artery bypass is a safe and reasonable alternative to primary amputation. Excellent limb salvage can be achieved if the bypass remains patent through the initial 30 days postoperatively.

Purpose: The purpose of this study was to examine the utility of carotid shunting in the context of eversion endarterectomy. A comparison of patients who underwent carotid endarterectomy by eversion with and without shunts was performed., Methods: Over a 5-year period, 2724 eversion carotid endarterectomies were performed. In most of these operations patients were under cervical block anesthesia. A shunt was used in 112 eversion endarterectomies (4.1%). Cervical block anesthesia was used in 103 patients (92.0%), general anesthesia was used in 5 patients (4.5%), and 4 patients (3.6%) were converted from cervical block to general anesthesia intraoperatively. The indications for shunting were neurologic deterioration in 99 patients (88.4%) who were under cervical block anesthesia, procedures performed in neurologically unstable or otherwise compromised patients who were under general anesthesia, and the operator's discretion in the remaining eight patients., Results: There was a combined stroke/death rate of 2.7% in the shunt group. These three cases included one death from myocardial infarction and one delayed death due to intracerebral hemorrhage after discharge. Shunt insertion was unrelated to the negative outcome in these two cases. One perioperative major stroke in the shunt group was identified. Follow-up averaged 12.3 months (range, 1-53 months)., Conclusion: Carotid shunts can be used effectively in the context of eversion endarterectomy. Shunt insertion is not associated with an increased stroke/death rate in these patients.

Recent studies have demonstrated the benefits of carotid endarterectomy (CEA) and risk factor control in preventing stroke in asymptomatic patients. In this study, the effect of the asymptomatic carotid atherosclerosis study (ACAS) on the frequency of CEAs performed and the outcome of such procedures on symptomatic and asymptomatic patients were analyzed. From 1990 to 1996, all patients undergoing CEA were prospectively entered into a computerized vascular registry. The number of procedures, indications, demographics, and early and late results were analyzed and compared with similar data compiled prior to the ACAS study. The total volume of CEAs performed increased from 66 in 1990 to 719 in 1996 (ratio 1:12.3). The ratio of symptomatic to asymptomatic patients changed from 1.75:1 in 1990 to 1:1.52 in 1996. The combined stroke/mortality rate dropped from 4.75% in 1990 to 2.15% in 1996. The stroke mortality in the asymptomatic group decreased significantly from 4.3 to 1.9% in the pre and post-ACAS groups respectively (P<0.0005). The stroke mortality of symptomatic patients remained constant at 2.1 and 1.4% respectively.Since the completion of ACAS in 1993, the number of CEAs performed on our service has increased tenfold. An increase in volume has translated into an improved stroke/mortality rate and significantly decreased length of stay.

Purpose: The long-term patency for infrapopliteal bypass grafting with prosthetic material is less than optimal. Our experience demonstrates a 40% patency at 2 years for these grafts. Several adjuvant techniques have been developed to improve patency rates, two of which are a remote distal arteriovenous fistula and the creation of a distal vein cuff. This study summarizes our experience with these two techniques., Methods: Between 1987 and 1998, 107 bypass graftings were performed to the below-knee popliteal or tibial vessels with the use of polytetrafluoroethylene. One group (48 bypass grafts) had polytetrafluoroethylene with adjuvant distal arteriovenous fistula (DAVF), and a second group (59 bypass grafts) was reconstructed with a distal vein cuff (DVC). The type of bypass grafting that was performed was based on surgeon experience and preference. Indications and demographics were similar in the two groups. All patients underwent the operation for limb-threatening ischemia, including gangrene (DAVF, 23%; DVC, 9%), ulceration (DAVF, 27%; DVC, 51%), and rest pain (DAVF, 50%; DVC, 40%)., Results: The primary patency rate was 48% and 38% at 3 years for DAVF and DVC, respectively. Secondary patency was 48% and 47% at 3 years, with limb salvage rates of 76% and 92% for DAVF and DVC, respectively (P <.05). Attempted thrombectomy without continuation of patency was undertaken in two patients with a failed DAVF. Attempts at restoration after thrombosis were made in eight patients with failed DVCs. Five patients underwent thrombectomy, of which four procedures were successful. Three patients had thrombolytic therapy, and two of these remained patent., Conclusion: Adjuvant techniques, including DAVF and DVC, produce acceptable long-term patency and limb salvage rates in bypass grafts performed to the below-knee popliteal and tibial vessels. This study suggests that DVCs may offer improved limb salvage rates and a greater opportunity for revision when bypass graft failure occurs.