Search

Objectives The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE). Methods This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis. Results Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01). Conclusion ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89–0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14–1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10–1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08–1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04–1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96–1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Background Lower extremity amputation (LEA) is a major surgical procedure with a high risk of significant morbidity and mortality. The objective of this study was to describe mortality and functionality outcomes following this procedure in a developing country. Methods This is a retrospective study of all patients undergoing LEA for non-traumatic etiology between 2007 and 2017. Medical records were used to retrieve demographics, comorbidities, and perioperative complications of identified patients. Patients were contacted to follow-up on their medical, postoperative care, and ambulatory status. Mortality and postoperative functionality rates were analyzed. Results The study included 78 patients. Median follow-up duration was 24 months. Hypertension (81%) and diabetes (79%) were the most common comorbidities. Mortality rates at 30 days, 1, and 5 years were 10.3, 29.2, and 65.5%, respectively. Mortality was significantly associated with age > 70 at amputation ( p = 0.042), hypertension ( p = 0.003), chronic kidney disease ( p = 0.031), and perioperative sepsis ( p = 0.01). Only 1.6% of patients were discharged into a specialized care center, and only 27% of patients were ambulatory postoperatively, although 90.5% were fitted with a prosthesis. Conclusions Survival following major amputation in a developing country is currently comparable to more developed regions of the world. Major discrepancy seems to exist in ambulatory status following the procedure. Discharge placement policies should be properly set, and rehabilitation centers funding should be increased. Awareness may also be warranted to educate patients and families about the value and positive impact of rehabilitation centers.

Purpose: Describe a hybrid approach to simplify management of complex aortoiliac occlusive disease (AIOD) extending into the common femoral artery (CFA). Methods: Retrospective review of 56 patients who underwent hybrid management of AIOD extending into CFA between January 2003 and February 2007. Two distinct hybrid approaches were compared: Inline (iliac stenting continuous with an open CFA reconstruction, 38 limbs in 37 patients) and tandem (noncontiguous stenting of an upstream iliac segment, 20 limbs in 19 patients). The median follow-up duration was 15 ± 12 months in the inline group and 24 ± 12 months in the tandem group. Results: Technical success was achieved in all but 1 procedure. Clinical and hemodynamic responses to the interventions and limb loss rates were comparable in both groups. Survival table analysis showed no significant difference between inline and tandem reconstructions. Conclusions: Inline stenting represents a lesser invasive revascularization choice in complex AIOD with contiguous involvement of the CFA.

Purpose: To report experience with aggressive recanalization approaches in chronic total arterial occlusion (CTO). Methods: Chronic total arterial occlusion recanalization was attempted on 112 limbs in 99 consecutive patients between January 1999 and December 2006. Results: There were 63 iliac arteries, 45 femoropopliteal arteries, and 4 occluded stents. Mean occlusion length was 8.7 ± 4.7 cm. Conventional recanalization was attempted first and was successful in 71 limbs (70%). Probing with the guidewire’s stiff end was attempted in 33 of the 41 procedures where conventional techniques failed and was successful in 18 (54%), improving the overall procedural success rate to 80%. For the remaining 15 limbs, home-made directional sharp needle recanalization was attempted in 11 and was successful in 9 (82%), further improving the overall recanalization success to 88%. Procedural complications were self-limited or managed nonoperatively. Conclusions: Aggressive recanalization techniques in CTO following failure of traditional means are safe and can substantially improve procedural success rates.

Kissing stent reconstruction of the aortoiliac bifurcation is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. New advances in delivery systems and stent design have enabled better anatomic results with kissing stenting. Long-term patency is generally excellent, although several factors may adversely affect patency and should be taken into account when devising the stenting configuration and selecting the device to be used. Geometric variables related to individual aortic anatomy and disease pattern (patient dependent) and stenting configuration (operator dependent) may have an impact on long-term patency. Kissing stent aortoiliac reconstruction is effective and durable, even with complex aortoiliac disease and long-segment occlusions. In our experience, TASC (TransAtlantic Inter-Society Consensus) C and D class disease is not necessarily a contraindication to aortoiliac stent reconstruction, especially in poor operative risk patients. Most restenoses are amenable to endovascular treatment, with excellent long-term assisted patency.

A case of poorly controlled renovascular hypertension and worsening renal insufficiency in a patient with prior aortic aneurysm replacement and a hepatic artery stenosis was treated with bilateral extraanatomic renal revascularization utilizing the celiac artery as an inflow. Three years following revascularization, her blood pressure is well controlled and her renal function is stable. Renal revascularization using the celiac trunk as an inflow source has not been previously reported. This case demonstrates that the celiac artery can be used for bilateral renal artery revascularization if the hepatic or splenic arteries are found to be inadequate as an inflow source.

The case of a 69-year-old woman with a complicated history of intrathoracic aortic arch and arch vessel reconstruction is reported. She presented with occlusion of multiple arch vessels and symptoms of cerebral ischemia. A remote femoral inflow route was used for revascularization of the arch vessels owing to the hostile nature of the arch reoperative field.

An unusual case of a nonhealing iatrogenic foot ulcer in a man with a remote history of a gunshot wound to the affected limb is presented. The patient had an untreated arteriovenous fistula of the popliteal artery and vein due to a gunshot wound 36 years ago. The etiology and management of such fistulae are discussed.

Infrainguinal bypass grafts are traditionally routed along the medial aspect of the lower extremity. In the presence of medial scarring, open wounds, or infection, an alternative routing may be necessary in order to safely revascularize the ischemic limb. Subcutaneous lateral routing of an infrainguinal bypass graft can be a useful alternative to conventional medial routing. We review the available literature on this topic and discuss the current indications and techniques for the lateral exposure of the infrainguinal vessels, as well as the techniques and pitfalls for lateral extraanatomic routing of lower extremity infrainguinal bypass grafts.

The purpose of this study was to compare the results of extra-anatomic femorofemoral crossover bypass grafting to the anatomic iliofemoral bypass grafting procedure in the treatment of patients with unilateral iliac artery occlusive disease with respect to patency and limb salvage. The records of all patients with unilateral iliac artery disease who underwent revas cularization between January 1988 and December 1995 at the University of Iowa Hospitals and Clinics (UIHC) were retrospectively reviewed; 108 patients were identified and divided into two groups. Group I (n=68; male/female=44/24) was composed of all patients who underwent a femorofemoral crossover extra-anatomic bypass. All patients who underwent an iliofemoral anatomic bypass constituted group II (n=40; male/female=24/16). The mean age for group I was 60 years (range 28-87) and for group II, 54 years (range 14-86). The medical risk factors between both groups were comparable. Except for the higher incidence of gangrene in group II the indications for surgery were comparable between both groups. (continued on next page) A polytetrafluoroethylene graft was used in 88% of group I patients and in 90% of group II patients (NS). In the remaining patients, an autogenous vein conduit was used. Two patients from group I (2.9%) died in the perioperative period (NS). Graft patency was assessed by clinical evaluation, Doppler-derived ankle/brachial indices, and color duplex imaging. The cumulative primary and secondary patency rates, limb salvage, and patient survival were calculated by use of life table analysis (SE These data suggest that there is no significant difference in the long-term results between the femorofemoral crossover bypass grafts and iliofemoral grafts. Both procedures result in acceptable patency and limb salvage rates. The femorofemoral bypass is, however, more attractive, for it can be performed under local anesthesia if needed and does not involve the creation of the retroperitoneal incision necessary with the iliofemoral bypass.

A twenty-six-year-old man was involved in a farming accident, whereby a corn head from a combine fell on his legs. He was transported by air care to the emergency room approx imately seventy-five minutes after the accident. Upon examination the patient was alert with a pulse of 100/minute, blood pressure 116/80 mmHg, and respiratory rate 20/minute. There was an anterior dislocation of the left knee with a wound in the popliteal fossa measuring 8 x 6 cm. There was a normal palpable left femoral pulse, but distal pulses were detectable only by Doppler. There was no evidence of an expanding hematoma or bruit. He had a left-sided foot drop with a cold, pale foot with diminished sensation. Roentgenograms of the lower extremities revealed an anterior dislocation of the left knee without any associated fracture. The patient was taken urgently to the operating room, and under general anesthesia a reduction of the anterior dislocation of the left knee, with debridement and irrigation of the wound, was done followed by stabi lization of the knee with an external fixator. The patient had palpable left posterior tibial and dorsal pedis artery pulses following the reduction. Intraoperative arteriography under fluoroscopy was then performed via the left femoral route by the Seldinger technique. This revealed a 50% 5-cm-long smooth stenosis of the left popliteal artery with normal distal runoff. It was decided to manage the patient's popliteal artery injury nonoperatively with anticoagulation and in-hospital serial observations. Duplex examination of the left popliteal artery confirmed the arteriographic findings. The patient was given intravenous heparin therapy for three days followed by warfarin for three months and is currently taking aspirin (325 mg/day). A follow-up duplex examination at one week and at one, six, and fifteen months following the injury revealed a normal healed popliteal artery.Traumatic knee dislocations have a well-known association with popliteal artery injuries. Because of a high amputation rate associated with missed or delayed diagnosis of popliteal artery injuries, early diagnosis and repair of such injuries is the standard of care.The authors describe the nonoperative management of this injury and review the literature on this subject.

The development of an aneurysm in an in situ bypass has not been reported to date in the major series of in situ bypasses. A review of the English literature did reveal one other report of an aneurysm developing following an in situ bypass. In this report, we describe a sixty-seven-year-old woman with a true aneurysm that developed in an in situ greater saphenous vein bypass six years after implantation.

Between January, 1988, and December, 1992, 336 autogenous vein bypasses were performed on the vascular service at The University of Iowa Hospital. Routine color duplex surveillance (CDS) identified 25 bypasses with a significant distal anastomotic stenosis that developed between one and thirty-one months postoperatively (mean nine months). These 25 „failing bypasses” underwent a revisional procedure following arteriographic confirmation of the location and severity of the lesion. The intraoperative completion arteriograms performed at the time of the original bypass procedure of these revised bypasses were critically analyzed. The length of the distal anastomosis, as well as the diameter of the distal vein conduit and artery (proximal and distal to the anastomosis) were measured in each case. In addition any anastomotic defect seen on the original intraoperative completion arteriogram was also noted. This same analysis was done for 50 consecutive vein bypasses that have remained primarily patent for two years or more and had normal duplex surveillance studies. Vein/artery diameter, anastomotic length/artery diameter, anastomotic length/vein diameter ratios were calculated for both the groups. Demographic characteristics, risk factors (diabetes mellitus, hypertension, coronary artery disease, renal failure, chronic obstructive pulmonary disease), indications for surgery, type of venous bypass conduit, and the outflow of the bypasses were comparable between these two groups. The results are depicted in the following table: [Table: see text] These data indicate that the geometry of the distal anastomosis does not play a significant role in the development of distal anastomotic stenosis. An uncorrected anastomotic defect on the completion arteriogram is a risk factor for bypass failure. Hence, patients with such defects should have these lesions corrected when they are initially identified at the time of the initial bypass procedure.

The outcome of 72 direct intra-arterial urokinase infusions was studied prospectively. Thirty four were performed for native arterial occlusion and 38 for bypass graft occlusion; the immediate success rates were 67.5 and 84% respectively. The overall incidence of complications was 26%. Median follow-up was 36 (range 1–60) months. Seventeen patients (27%) died during follow-up; nine (14%) required a major amputation. Among patients with native arterial occlusion, 29% had no adjunctive procedure after thrombolysis; of these patients, 85% remained patent at a median of 21 (range 3–42) months. Among bypass occluded patients, only two (6%) had no lesion revealed after successful lysis; both bypasses remain patent at 54 and 58 months respectively. For patients treated with balloon angioplasty immediately after successful thrombolysis, 62% with native arterial occlusion remained patent at a median of 39 (range 2–60) months, whereas only 27% of bypass occlusion patients were patent at a median of 11 (range 2–40) months. Of patients requiring a surgical procedure after thrombolysis, 23 new bypasses (15 vein, eight prosthetic) were placed (nine in native arterial occlusion patients, 14 in bypass occlusion patients). In addition, there were 15 other surgical procedures, including six thrombectomies, four vein patch angioplasties, four vein jump grafts and one endarterectomy. The primary and secondary patencies for the 15 new vein bypasses placed were 81 and 88% respectively at a median follow-up of 36 months. Good immediate results were experienced with urokinase thrombolysis for peripheral arterial and graft occlusions. However, multiple adjunctive procedures were required to maintain patency. Balloon angioplasty yielded reasonable late patency for the native arterial group but poor patency for the bypass group. Replacement with a new bypass gave the best long-term patency in both groups. These data suggest that thrombolysis is a reasonable first-line treatment for limb ischemia due to native arterial occlusion. However, for bypass graft occlusion, the results, despite initial success, are not durable.

Ten years after placement of a thoracofemoral graft for aortoiliac occlusive disease, a mid graft pseudoaneurysm was identified following new trauma to the left flank. An aortogram confirmed the pseudoaneurysm. An initial attempt at repair with an endovascular stent failed; an open repair was required.

A forty-eight-year-old woman was evaluated for left hemispheric and transient left monocular symptoms referable to the carotid bifurcation. She was found to have an intrathoracic bifurcation of the left common carotid artery. The angiogram showed a 95% stenosis of the proximal left internal carotid artery arising at an intrathoracic location off a short trunk of the left common carotid artery. She had a history of a Blalock-Taussig shunt and a later total correction of Fallot's tetralogy. Operative correction of the carotid lesion consisted of cervical transposition of the left internal carotid artery to the left external carotid artery. Her postoperative course was uneventful, and follow-up for nearly a year continues to demonstrate a widely patent reconstruction with resolution of her symptoms. The carotid bifurcation may be found at varying locations in the neck; however, a review of the English literature did not disclose any reports of an intrathoracic carotid bifurcation. Given the potential for misdiagnosis, this abnormality should be considered when the bifurcation is not found in its more usual locale on duplex interrogation of this artery.