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Objective: Endovascular placement of prosthetic valves is currently in clinical trials as treatment for lower extremity venous hypertension caused by valvular insufficiency. Femoropopliteal vein sizing is a critical factor in treatment planning. A wide diameter range could influence selection of an endoprosthesis. Quantitative data describing intrasubject vein diameter variation are scant. We measured vein diameters with ultrasound imaging to assess minimum-maximum diameter range under forced conditions of venoconstriction and venodilatation. Methods: Diameter of the common femoral vein (CFV), proximal femoral vein (PFV), mid-femoral vein (MFV), and distal femoral vein (DFV) in the thigh and the popliteal vein (PV) was measured in the morning under conditions of minimal venodilation and in the afternoon under conditions of stressed venodilatation that included activities of daily living and a 5-minute treadmill walk. Measurements were obtained twice on two different days in both extremities in 20 subjects with CEAP clinical classification C0 (n = 10), C3 (n = 7), C4 (n = 1), or C5 (n = 2). Results: Average vein diameter increased, from 11.2 ± 2.5 (SD) mm to 14.5 ± 2.3 mm at the CFV, from 6.9 ± 1.8 mm to 9.4 ± 1.9 mm at the PFV, from 6.9 ± 1.6 mm to 9.0 ± 1.8 mm at the MFV, from 7.3 ± 1.7 mm to 9.1 ± 1.5 mm at the DFV, and from 8.4 ± 1.4 mm to 9.7 ± 1.8 mm at the PV (P

Purpose: Treatment of chronic venous valvular insufficiency requires understanding of the hemodynamics of perforating veins. To preserve normal veins or veins that can function normally once primary sources of valvular insufficiency are removed, a better understanding of the diameter-reflux relationship is desirable. We measured reflux and diameters in 500 perforating veins of patients with varicose veins (C2EPASPPR). Methods: Color flow duplex ultrasonography scanning was performed with the patient standing. Perforating veins were mapped medially in the thigh and medially, laterally, and posteriorly in the calf. Reflux was defined as reverse flow that lasted longer than 0.5 seconds. Diameters were measured on B-mode transverse projections at the crossing of the fascia. Competent versus incompetent vein diameters were compared by means of Student t test, one-way analysis of variance, and Bonferroni t test. Results: Diameters of competent and incompetent perforators averaged 2.5 ± 0.9 mm (n = 17) and 4.7 ± 1.9 mm (n = 17) at the medial thigh (P < .0002), 2.2 ± 0.8 mm (n = 179) and 3.7 ± 1.0 mm (n = 210) at the medial calf (P < .0001), 2.2 ± 0.6 mm (n = 13) and 3.5 ± 0.8 mm (n = 37) at the posterior calf (P < .0001), and 2.1 ± 0.8 mm (n = 9) and 3.3 ± 0.7 mm (n = 18) at the lateral calf (P < .003), respectively. Perforating vein diameters of 3.5 mm or larger in the calf and thigh were associated with reflux in more than 90% of the cases. Conclusion: An enlargement in the diameter of the perforating veins of 1 to 1.5 mm in the calf or 2 mm in the thigh of patients with varicose veins could be the difference between normal flow and reflux. Further studies are needed to confirm if elimination of reflux in patients with primary varicosity will transform incompetent perforators to competent ones. (J Vasc Surg 1999;30:867-75.)

Purpose: Management decisions regarding carotid artery disease are critically dependent on stenosis but have been made difficult because of conflicting methods used to determine such stenosis. The increasing use of duplex ultrasound scanning has conventionally depended on Doppler velocity measurement, an indirect method for calculating carotid stenosis. Recent technical advances have improved the quality of B-mode/color-flow ultrasound scan imaging (USI). We tested prospectively whether USI was clinically effective as the primary criterion for estimating carotid stenosis. Methods: Transverse and longitudinal USI, Doppler velocity, and arteriography data were obtained sequentially and independently for 713 carotid bifurcations. The internal carotid artery (ICA) residual lumen, the local outer diameter at the stenotic site, and the diameter distal to the bulb were measured in a representative USI longitudinal section. The peak systolic velocity and the end diastolic velocity (EDV) were measured at the stenosis. Local stenosis as determined with USI was compared with the x-ray arteriographic clinical radiology interpretation (XRI). As the primary method, radiologists compared the residual lumen with the distal ICA diameter, as recommended by the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study. Analysis was by means of the USI positive predictive value (PPV) and negative predictive value (NPV) of the XRI findings, with the assumption that 80%, 70%, and 60% local stenosis with USI related to 70%, 60%, and 50% stenosis with XRI, respectively. Results: All 56 ICA occlusions as determined with USI were confirmed with XRI. When the USI showed 80% to 99% stenosis, the PPV of the XRI showing 70% to 99% stenosis was 94% (116/123). Two ICAs that were shown to be severely diseased with USI appeared to be occluded with XRI. For

Purpose: Although much attention has been focused on lower extremity deep venous thrombosis (LEDVT), there is a relative paucity of data regarding the impact of upper extremity deep venous thrombosis (UEDVT) on morbidity and mortality rates. To increase our knowledge with the latter disease, we have reviewed our experience at our institution with 170 patients who had brachial, axillary, and subclavian vein thromboses. Methods: Over the past 5 years, UEDVT was diagnosed in 170 patients by duplex scanning. The indications for duplex examination were either upper extremity swelling (95%) or as part of the workup for pulmonary embolism (5%). There were 103 women (61%) and 67 men (39%), with ages ranging from 9 to 101 years (mean, 68 ± 17 years). The diagnosis was made in 152 patients (89%) while they were admitted to the hospital and in 18 patients (11%) in the outpatient clinic. Risk factors included presence of a central venous catheter or pacemaker in 110 patients (65%), malignancy in 63 patients (37%), concomitant LEDVT in 19 patients (11%), and history of LEDVT in 18 patients (11%). Fifty-six patients (33%) had multiple risk factors, whereas 36 patients (21%) had no obvious risk factor. Results: The 1-month and 3-month mortality rates for the entire study group were 16% and 34%, respectively. Patients who had concomitant LEDVT, were 75 years of age or older, and were not treated with anticoagulation medication had a significantly higher 1-month mortality rate. Patients whose diagnoses were made in the outpatient setting were statistically younger and had a lower 3-month mortality rate when compared with the patients whose diagnoses were made as inpatients. Pulmonary embolism was documented by ventilation/perfusion scan in 12 patients (7%). Although no patient in the group in which UEDVT was diagnosed on an outpatient basis was documented to have a pulmonary embolism and 12 patients (8%) in the inpatient group had pulmonary emboli, this difference was not statistically significant. Anticoagulation medication did not totally prevent pulmonary embolism in this review. All patients were followed-up for between 0 to 49 months (mean, 13 ± 1 months). No swelling of the affected arm was observed in 145 patients (94%); four patients complained of mild intermittent swelling (2%), and seven patients reported significant swelling (4%). Conclusions: Contrary to previous reports, these data suggest that UEDVT is associated with a low incidence of postthrombotic upper extremity swelling, but a significant incidence of pulmonary embolism and rate of mortality. This review suggests that UEDVT is at least as serious a disease entity as LEDVT and should be managed as aggressively as LEDVT. (J Vasc Surg 1997;26:853-60.)

Purpose: Autogenous vein bypass grafts to infrapopliteal outflow sites have patency and limb salvage rates significantly superior to those obtained with prosthetic grafts. However, when infrageniculate bypass is required for limb-threatening ischemia in the patient lacking suitable autogenous veins, nonautogenous reconstruction or primary amputation are the only other alternatives. Methods: During a 2-year period we implanted 25 cryopreserved allograft saphenous vein bypass grafts in 24 patients (median age 76 years) with tissue necrosis (20 patients), rest pain (4 patients), or acute ischemia (1 patient); 16 patients were men and 8 were women. As many as six previous revascularizations were performed in 79%; two grafts extended to the infrageniculate popliteal artery; 23 grafts extended to a paramalleolar vessel. Results: Secondary patency at 1 month was 87%, but only 36% at 1 year. Use of warfarin (Coumadin) failed to improve the patency rate (five of nine occlusions treated with Coumadin versus eight of 16 not treated with Coumadin). Only eight of 24 patients are alive with open grafts; nine patients have died. Conclusions: Unheralded occlusions more typical of prosthetic graft failure tempered the initial enthusiasm and effectiveness of vein allografts. All autogenous options must be exhausted to complete distal, secondary revascularization before resorting to nonautogenous conduits. Use of allograft veins must be viewed with continued skepticism. (J VASC SURG 1993;18:553-60.)

As vascular surgeons, we performed 376 percutaneous transluminal angioplasties as follows: aorta and iliac arteries (148), infrainguinal arteries (191), and bypass grafts (21). Sixteen procedures were attempted but not completed. Neodymium-yttrium-aluminum-garnet laser thermoprobe was successfully used prior to balloon dilatations in 49 procedures. In contrast to our experience with operative intervention, percutaneous transluminal angioplasty was performed more frequently for claudication (75%), nondiabetics (72%), and women (45%). Median age was 71 years. Percutaneous transluminal angioplasty either preceded or followed proximal or distal open reconstruction in 58 extremities. Primary patency rates for iliac percutaneous transluminal angioplasties were: 94% at one month, 93% at six months, and 88% at one year. For infrainguinal percutaneous transluminal angioplasties they were 95%, 82%, and 70% at 1, 6, and 12 months, respectively. Repeat percutaneous transluminal angioplasty increased the one-year patency rates to 92% and 86% for iliac and infrainguinal percutaneous transluminal angioplasties, respectively. Preliminary data indicate that the six-month secondary patency rates were 82% for laser-assisted percutaneous transluminal angioplasty and 65% for percutaneous transluminal angioplasty of distal bypass grafts. The implementation of balloon angioplasty was facilitated by our 21 years of experience with arteriography. Percutaneous transluminal angioplasty has become a valuable adjunct to the practice of vascular surgery by expanding the therapeutic options for managing peripheral vascular occlusive disease.

Although balloon angioplasty for the management of failing bypass grafts has been well documented, little mention has been made of its use in treating the occlusive lesion within the native artery after a failed bypass graft. We report our experience with five patients in whom successful balloon angioplasty was carried out subsequent to failure of a femoral popliteal bypass graft. Increasingly aggressive percutaneous therapy of arterial occlusive disease may now be expanded to include a unique group of patients with chronically failed bypass grafts and occlusive disease within the native artery conducive to percutaneous transluminal angioplasty. This group of patients would previously have been relegated to repeat bypass grafts with its inherently inferior patency and recognized added technical demands. Percutaneous balloon angioplasty appears to be a plausible alternative in selected cases for repeat lower extremity revascularization.

We measured ankle/arm pressure indexes and blood flow rates before and after performing percutaneous transluminal angioplasty in 36 extremities. Flow rates through the leg were determined with a magnetic resonance blood flow scanner. All patients had claudication; one had gangrene, another had an ulcer, and two complained of rest pain. The median age was 65 years, and 72% were men. There were 25 dilations of the iliac artery, 12 of the superficial femoral artery, and eight of the popliteal arteries; nine patients had two arterial segments dilated. Nineteen legs had ankle/arm pressure indexes before percutaneous transluminal angioplasty of less than 0.80 (range 0.51 to 0.75); their flow rates averaged 40 ± 20 (SD) ml/min. After percutaneous transluminal angioplasty flow and pressure increased significantly in 14 of these 19 legs, and three had no hemodynamic improvement; in one leg only pressure and in another only flow increased significantly. The remaining 17 extremities had ankle/arm pressure indexes before percutaneous transluminal angioplasty ranging from 0.81 to 1.09; their flow rates averaged 53 ± 27 (SD) ml/min. Abnormal flow rates were detected in 15 of these 17 extremities. With near-normal ankle/arm pressure indexes no significant increase in pressure was anticipated. Flow rates augmented to 75 ± 28 (SD) ml/min after percutaneous transluminal angioplasty; a significant increase in flow was noted in 12 legs (71%). For patients with ankle/arm indexes before percutaneous transluminal angioplasty. of less than 0.80, either pressure or flow measurements should corroborate the benefits of the operation, whereas if the ankle arm index is greater than 0.80, flow measurements are most likely to substantiate changes in peripheral hemodynamics. (J Vasc Surg 1989;10:338–42.)

The results of 160 infrainguinal bypasses with arm vein grafts were analyzed. Seventy-three arteriograms were reviewed to identify early and late graft defects; arteriographic findings paralleled those described for saphenous vein grafts. Intimal fibrosis during the first postoperative year, observed in 16 grafts, was the most common defect. Aneurysmosis and elongation were rare, resulting in two graft replacements. Patency and limb salvage rates were calculated for 88 single-length femorodistal bypass grafts; the other 72 were inflow (eight) or outflow (22) jump grafts, sequential (eight) and composite autogenous vein grafts (34). The primary and secondary patency rates for single-length grafts were 74% and 80% at 1 year and 51% and 57% at 5 years, respectively. The limb salvage rate at 5 years was 82%. The survival rate for all patients was 44% at 5 years. These findings reconfirm our use of arm veins as bypass grafts when the saphenous vein is unavailable. (J VASC SURG 1986;4:416-27.)

Preoperative noninvasive imaging of the veins of the upper extremities has been included in the protocol to select an autogenous vein for a distal bypass in the lower extremity. Arm veins are sought as bypass grafts when the saphenous vein is absent or not usable. Duplex ultrasound provided images of the cephalic and basilic veins in 10 patients in whom visual inspection failed to reveal usable grafts. All arm veins implanted were at least 2 mm (range 2 to 6 mm) in internal diameter determined by ultrasound and were, on the average, 2 mm larger when unroofed. This noninvasive technique has decreased the number of fruitless surgical explorations to obtain a suitable arm vein and has increased the use of arm veins by revealing veins previously not anticipated by physical examination, which virtually eliminated the use of nonautogenous conduits in our practice.

Two hundred forty-three bypasses to paramalleolar arteries were performed in 224 extremities of 208 patients since 1971; 166 were implanted in men (68%) and 77 in women (32%). The median age was 73 years. Gangrene (61%), nonhealing ulcer (15%), rest pain (22%), and trauma (2%) were the indications for bypass. Usual risk factors were noted: diabetes (65%), smoking (51%), heart disease (46%), and hypertension (45%). The extent of occlusive disease dictated three graft configurations: long grafts originating in arteries proximal to the adductor tendon (n = 111), short grafts originating at or below the popliteal artery (n = 88), and jump grafts originating near the distal end of a previous femorodistal bypass (n = 44). The association between diabetes (incidence 80%) and gangrene (75%) in patients with short grafts was statistically significant (p less than 0.01). The 2-year secondary patency rate of long in situ grafts was 92% compared with 72% for other autogenous vein long grafts. The limb salvage rate for all autogenous vein long grafts was 90% at 3 years. The secondary patency rate at 3 years for short grafts was 81% and the limb salvage rate was 80%. There were four amputations with patent grafts. Primary and secondary patency rates of jump grafts were similar (53%), whereas the limb salvage rate was 89% at 2 years. Patency and limb salvage rates of rarely employed nonautogenous conduits were less than 35% at 1 year (long grafts). Bypass grafts to the ankle and foot are effective and durable and should be performed with autogenous vein.

We placed 20 bypass grafts to the lateral plantar artery in 18 extremities to salvage feet with wet (12) or dry (six) gangrene; 15 grafts were implanted in men (75%), and five were implanted in women (25%). The median age was 65 years. All except two patients had diabetes; eight were treated with insulin. One patient had Buerger's disease, and another had vasculitis with chronic lymphocytic leukemia. History of smoking (65%), hypertension (53%), heart disease (71%), and osteomyelitis in the foot (35%), were noted. Cultures were positive in 15 gangrenous feet, 11 with gram-negative bacilli. Four long femoroplantar bypasses were placed. Ten short grafts were placed from the popliteal artery, and six jump grafts were placed distal to a femoropopliteal or tibial bypass. Hospital stay ranged from 8 to 38 days (median 16 days), and there were two in-hospital deaths. Transmetatarsal or button toe amputations were performed in nine feet. There were two below-knee amputations, one with a patent graft, for a foot salvage rate of 89% at 2 months. In four instances the gangrenous ulcers took longer than 6 months to heal; all other wounds healed within 6 months. The primary and secondary patency rates were 85% at 1 month, and 73% at 3 months and thereafter. Four of five graft failures occurred in the two legs with repeat bypass graftings. All patients with successful revascularization are able to walk, and seven returned to work full time.