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A rare and lethal vascular condition is the communication of the thoracic aorta and tracheobronchial tree. Typically, the development occurs after open or endovascular aortic repair that has been complicated by infection and usually presents with hemoptysis as the heralding event, which can lead to massive hemorrhage. Computed tomography angiography remains the diagnostic imaging modality of choice. Medical management will be futile, with the need for expedited operative intervention via open, endovascular, or hybrid open and endovascular repair., (© 2022 The Author(s).)

True aneurysms of the innominate artery are rare. Successful axial reconstruction in the past has required a combined cervical and transthoracic approach with placement of a prosthetic graft. We describe herein the occurrence of an innominate artery aneurysm that extended to and involved the proximal common carotid artery and subclavian artery in a 63-year-old woman. The patient presented with thomboembolic sequelae in her fingertips and had a pulseless upper extremity. Successful aneurysmectomy and axial reconstruction with a bifurcated graft was achieved by using cervical exposure alone. A subsequent staged revascularization of the upper extremity was successfully accomplished with a brachial to radial artery bypass and ulnar artery transposition.

Purpose: Acetazolamide (ACZ)-enhanced single photon emission computed tomography (SPECT) scans can assess both cerebral perfusion and vascular reactivity. Patients with asymptomatic critical carotid artery stenosis were evaluated for cerebral vascular reactivity to determine the effect of extracranial occlusive disease and the effect of carotid endarterectomy (CEA) on intracerebral reactivity., Methods: In 44 patients with asymptomatic critical carotid artery stenosis, cerebral perfusion and vascular reactivity were assessed before CEA with resting and ACZ-enhanced SPECT scans. All patients had a 70% or greater ipsilateral internal carotid artery stenosis. Preoperative ACZ-enhanced SPECT scans were obtained, usually 5 days before CEA. Postoperative ACZ-enhanced SPECT scans were obtained in 30 patients., Results: Preoperative SPECT scans were asymmetric, revealing focal (n = 19) or global (n = 15) decreased reactivity in 34 patients (77%). Ten patients had symmetric or normal reactivity. After CEA, 23 patients demonstrated an improvement in reactivity ipsilateral to the side of surgery. The remaining seven patients failed to improve after surgery., Conclusion: Although all patients had a high-grade internal carotid stenosis, nearly a quarter of the patients had excellent intracerebral collateral flow. Only 71% of patients demonstrated improved intracerebral vasoreactivity after CEA. The lack of improvement in the other patients may have resulted from intracerebral pathology or lack of improvement in the extracranial carotid hemodynamics.

Purpose: The long-term sequelae of inferior vena caval (IVC) resection during retroperitoneal lymph node dissection for metastatic nonseminomatous germ cell testis tumor (NSGCT) were assessed., Methods: Between December 1973 and September 1996, 2126 of our patients underwent RPLND for retroperitoneal nodal metastases from NSGCT; 955 had bulky disease (stages B2, B3, or C) after cytoreduction chemotherapy. Of this latter group, 65 patients (6.8%) required infrarenal IVC resection during tumor excision for cure. Our protocol does not include IVC reconstruction in such cases. Indications for IVC resection included tumor encasement or encroachment, postchemotherapy desmoplastic compression, or thrombus with tumor or clot in which cavotomy and thrombectomy cannot be performed., Results: Twenty-four of the 65 patients (postoperative follow-up period range, 11 months to 16 years; median, 89 months) were alive and able to be examined or interviewed by written and/or phone survey to assess the long-term morbidity of their IVC resection. Based on the 1994 American Venous Forum International Consensus Committee reporting standards, the clinical classifications of these 24 patients were C0A (4), C3S (4), C4A (2), C4S (13), and C6A (1). Long-term disability was mild or absent in 75% of these patients., Conclusion: Only 1 (4.2%) of the patients surveyed had chronic venous sequelae that would fulfill the accepted criteria for subsequent elective IVC reconstruction. Despite recent reports of IVC reconstruction demonstrating relatively good patency rates and low morbidity, the addition of such a complex, time-consuming procedure to extensive retroperitoneal lymph node dissection for metastatic NSGCT involving IVC resection is generally not necessary.

Purpose: We present a review of 35 patients who underwent an operation for subclavian (n = 18) or axillary (n = 17) vessel injury. In some patients, both an artery and a vein were damaged, resulting in a total of 30 arterial and 16 venous injuries., Methods: The wounding source included a gunshot (n = 19), a stab wound (n = 9,) and blunt trauma (n = 7). Seven patients had hypotension and were taken immediately to the operating room. Seventeen patients had diminished or absent pulses, whereas 13 patients had normal pulses despite an arterial injury. Associated injuries included nerve injury (n = 15), pneumohemothorax (n = 5), and fractures (n = 7). Angiography in 21 patients demonstrated an intimal flap (n = 8), extravasation (n = 5), a pseudoaneurysm (n = 3), an arteriovenous fistula (n = 2), and occlusion (n = 1). Two angiograms were normal. Arterial repair was accomplished by interposition graft (n = 17), primary repair (n = 9), patch angioplasty (n = 3,) and ligation (n = 1)., Results: No functional deficits occurred in patients with an isolated vascular injury. Seven patients with associated brachial plexus injuries experienced severe disability. One arm of a patient was amputated. Two patients died., Conclusions: The use of angiography helps to confirm and localize injuries. Prompt correction of the vascular injury avoids disability resulting from ischemia. Although the amputation rate is low with vascular repair, the functional disability resulting from associated nerve injuries can be devastating.

Purpose: To evaluate the patency and hemodynamic impact of a cryopreserved allograft venous valve transplanted to the superficial femoral vein (SFV) of a canine insufficiency model aided by a distal arteriovenous fistula (dAVF)., Methods: Eight greyhounds had intravenous hemodynamic parameters measured (venous filling time [VFT], 90% of venous refilling time [VRT90], and simulated ambulatory venous pressure [AVP]) before (T0) and after complete hindlimb venous valvulotomy (T1) to produce venous insufficiency. Simultaneously, a valve-containing vein segment was harvested from the opposite SFV or external jugular vein (n = 1) and cryopreserved. Three weeks later a blood type-matched cryopreserved valve was transplanted to the insufficient SFV aided by a low-flow (n = 4) or high-flow (n = 4) dAVF. The fistula was ligated in 3 to 6 weeks, and venous indexes (T2) were obtained 3 weeks later. Analysis of variances compared the venous indexes at T0, T1, and T2 for statistical significance. Gross and histologic inspection assessed valve integrity., Results: Two valves aided by a low-flow dAVF exhibited thrombosis and scarring. The hemodynamics of the six remaining valves demonstrated normalization of the VRT90, an AVP consistent with insufficiency, and a VFT between normal and total venous insufficiency. The patent valves were normal on gross examination and by histologic examination with signs of normal external healing., Conclusions: A cryopreserved venous valve allograft transplanted to the SFV of an incompetent hindlimb partially corrects venous hemodynamics. A high-flow arteriovenous fistula most consistently preserves transplant patency.

Purpose: This retrospective review of femorodistal vein grafts was analyzed to determine the usefulness of various graft surveillance criteria., Method: The surveillance schedule involved evaluations at 1 month, every 3 months the first year, and then every 6 months. Salvage intervention or graft occlusion occurring within the next follow-up interval defined surveillance end points. One hundred two grafts (329 surveillance visits) had an ankle/brachial index (ABI). A duplex scanning-determined midgraft peak systolic flow velocity (PSFV) was available for 81 grafts (262 visits). Forty-eight grafts (137 visits) had both a PSFV and entire graft duplex scanning (EGDS) to determine stenosis greater than 50%, whereas 40 grafts (91 visits) had simultaneous ABI and EGDS., Results: When a greater than 15% decrease in ABI denoted an abnormal surveillance study result, a positive predictive value (PPV) of 24.3% and negative predictive value of 94.5% were noted. Similarly, a PSFV cutoff of less than 35 cm/sec demonstrated values of 26.3% and 94.2%, respectively. When an EGDS of greater than 50% stenosis or a PSFV of less than 35 cm/sec were the cutoff criteria, the PPV was 36.7% and negative predictive value 99.1%, whereas characterizing abnormal results further with ABI (> 15% decreases) increased the PPV to 83.3%., Conclusion: The combination of an EGDS, midgraft PSFV, and ABI provides optimal follow-up for our patients with a femorodistal vein graft.

Purpose: The objectives were to transplant a venous valve into the popliteal vein of a canine insufficiency model that would maintain long-term function and then to measure the hemodynamic benefit of such a valve., Methods: Indexes of venous valvular function, including venous filling time, 90% of venous refilling time, and simulated ambulatory venous pressure, were measured in 11 greyhounds before intervention (Control) and after hind limb venous valvulotomy, which produces chronic venous insufficiency. Three weeks later a valve-containing segment of external jugular vein was transplanted to the popliteal vein with (n = 6) or without (n = 5) a distal arteriovenous fistula. The fistula was ligated in 4 to 6 weeks. Repeat venous indexes were obtained an average of 2 weeks after the last operative intervention. Gross anatomic inspection +/- duplex scanning performed before the animals were killed were used to distinguished normal from damaged valves., Results: Four of five simple valve transplants demonstrated scarring and/or thrombosis and the average venous filling time, ambulatory venous pressure, and 90% of venous refilling time were consistent with chronic venous insufficiency and/or obstruction. One fistula failed in the six valve distal arteriovenous fistula transplants, and that valve was incompetent. Analysis of the remaining five functional valves demonstrated venous filling time consistent with chronic venous insufficiency, normalization of ambulatory venous pressure, and 90% of venous refilling time between normal, and chronic venous insufficiency. These valves appeared normal., Conclusions: Popliteal vein valve transplant anatomy is preserved by an adjunctive distal arteriovenous fistula, and a competent valve transplant improves postexercise venous hemodynamics to approach those of a normal limb.

Purpose: This study evaluated an endovascular technique for occlusion of arteriovenous fistula when performing saphenous vein in situ bypass grafting., Methods: In 31 limbs femoropopliteal (17) or femorotibial (14) in situ bypass grafting was performed for claudication/aneurysm (4), rest pain (6), or tissue loss (21). A valvulotome was used for valve lysis. Saphenous vein branches were identified with angioscopy in 16 limbs or with fluoroscopy in the remainder. An electronically steerable endovascular catheter was used to deliver platinum coils into the venous tributaries to occlude them., Results: The maximal number of coils placed in any limb was nine. Most operations were performed with only a groin incision (length = 9.8 +/- 1.6 cm) and a distal incision (length = 16.8 +/- 6.5 cm). Wound complications occurred in four limbs, whereas four limbs developed localized superficial thrombophlebitis. The postoperative ankle-brachial index increased to a mean of 0.91 +/- 0.12. Postoperative duplex imaging revealed a missed arteriovenous fistula in 12 limbs. Two were surgically ligated, whereas the remainder were embolized in the radiology suite. Postoperative length of hospitalization was 4 +/- 2 days in uncomplicated cases. Follow-up revealed five graft occlusions. Occlusion occurred at 12 hours, 2 weeks, and 6, 14, and 15 months after operation. Although there were no perioperative deaths, two patients have died of unrelated causes., Conclusion: This endovascular technique of arteriovenous fistula embolization decreased the length of the surgical wounds, and patients were discharged 4 +/- 2 days in uncomplicated cases. The ultimate test of its efficacy, however, will be long-term functional results.

Two-dimensional echocardiography can detect regional wall motion abnormalities resulting from myocardial ischemia produced by dobutamine infusion. In 60 patients undergoing elective aortic surgery (27 with aneurysms, 33 with occlusive disease), we evaluated the ability of dobutamine stress echocardiography to predict perioperative cardiac events. Echo images were obtained at rest and during incremental dobutamine infusion to a peak dose of 50 micrograms/kg/min, unless another test end point was reached (angina, heart rate greater than or equal to 85% of age-predicted maximum, significant ST segment depression, or new stress-induced wall motion abnormalities). Dobutamine stress echocardiography results were stratified as follows: group I, no wall motion abnormalities; group II, resting wall motion abnormalities unchanged with stress; group III, stress-induced worsening of resting wall motion abnormalities; group IV, new-onset wall motion abnormalities with stress. Twelve cardiac events occurred within the first 30 postoperative days: three cardiac deaths (5%), six nonfatal myocardial infarctions (10%), two patients with unstable angina (3.3%), and one patient with asymptomatic elevation of creatine phosphokinase MB isoenzymes without electrocardiographic changes (1.7%). Eleven events occurred in the 38 patients with an abnormal dobutamine stress echocardiograph (groups II to IV); in contrast, only one of 22 patients with a normal dobutamine stress echocardiograph (group I) had a cardiac event. These event rates (29% vs 4.6%) differed significantly (p less than 0.025). Dobutamine stress echocardiography is a new, safe, rapid, relatively low cost, noninvasive, nonexercise cardiac stress test for risk stratification before major vascular surgery.

Twenty-five patients were tested before and after carotid endarterectomy with resting and acetazolamide enhanced single photon emission computed tomography (SPECT) scans with hexamethyl propyleneamine oxine (HMPAO) or iofetamine hydrochloride I123 (123I labeled IMP), both widely available radiopharmaceuticals. Twenty preoperative SPECT studies were asymmetric, revealing focal or diffuse decreased perfusion reserve, and 13 also demonstrated infarcts. Five patients had symmetric (normal) studies. After carotid endarterectomy, 22 cases had changed flow distribution patterns. Usually improvement of reactivity ipsilateral occurred to the area operated on. In four, contralateral improvement was also found. Three of the patients who had preoperative symmetrical scans had increased ipsilateral reactivity after surgery indicating previous global loss of reactivity. Acetazolamide SPECT scans demonstrate a decreased perfusion reserve in 20 patients with carotid artery stenosis, indicating reduced perfusion and poor collateral circulation. Postoperative studies confirm improvement by demonstrating recovery of vascular reactivity in 84% of the patients. Acetazolamide enhanced SPECT scans may be helpful in providing objective evidence for selection of patients for carotid endarterectomy, especially in those who have an 80% carotid artery stenosis, but are asymptomatic.

This report evaluates the ability of a single competent (native or experimental) superficial femoral vein valve to correct canine hindlimb venous insufficiency. The time to maximal ankle venous pressure after standing (VFT) and to 90% of that time after exercise (VRT90), and the minimal pressure after exercise (AVP) were measured in 17 greyhounds before intervention, after only the superficial femoral vein valve remained (n = 5), and after complete lower limb venous valvulotomy (n = 17). Three weeks later, 12 dogs underwent a native (n = 4) or experimental (n = 8) autogenous venous valve transplantation. Immediately and at 3 weeks after transplantation, venous pressure measurements were obtained. The manual strip test confirmed valve competence at the time of sacrifice. Only one valve transplant became incompetent. Immediately after single superficial femoral vein valve construction, VFT, AVP, and VRT90 measurements were not significantly different from normal. Three weeks after transplantation the AVP measurements were consistent with an insufficient venous system, whereas the VRT90 measurements were between and statistically different from both the control and totally incompetent system (p less than 0.05). After the native valve but not the experimental valve transplantations VFT normalized. These data suggest that insertion of a single competent superficial femoral vein valve into an incompetent lower limb venous system corrects venous pressure measurements initially but soon provides only a partially competent system. The experimental valve, although competent, is less responsive than a native valve.

A mathematic model of unilateral iliac vein obstruction was used to establish the theoretic basis for selecting saphenous vein or a larger diameter prosthetic cross-femoral venous bypass graft for relief of obstructive venous hypertension. Common femoral vein resting and postexercise peak flows, and common femoral vein and saphenous vein diameters were measured in 18 healthy individuals and used to estimate the pressure gradient (dP) across 20 cm long cross-femoral venous bypass grafts of saphenous vein or 4, 6, 8, 10, and 12 mm prosthetic conduits, in the presence of a transpelvic venous collateral network of varied cross section. The upper limits of normal for the gradients in our model (dPstd) were set at 4 mm Hg for resting flows and 6 mm Hg after exercise. Mean saphenous vein diameter was 4.3 +/- 0.22 mm, which was 36.5% +/- 1.73% of common femoral vein diameter. When the saphenous veins of two thirds of the individuals in our study were used as theoretic cross-femoral venous bypass conduits, greater than 80% of postobstruction peak cross-femoral venous bypass graft flow had to be carried by collaterals to maintain a gradient less than or equal to dPstd. We demonstrated that 4.5 to 6.0 mm diameter saphenous cross-femoral venous bypass grafts would be hemodynamically efficacious in relieving venous hypertension, but only when implanted in parallel with an existing venous collateral network that limited the preoperative dP to 4.5 to 7.5 mm Hg at resting flows and 7.0 to 11.5 mm Hg after exercise; only 44% of saphenous veins were adequate for cross-femoral venous bypass grafts by these criteria.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of treatment after excision of infected arterial grafts were analyzed as a function of aortic/arterial wall cultures and duration of antibiotic therapy in 33 patients. Four patients died during surgery and 29 patients were observed for periods ranging from 2 weeks to 76 months. Negative arterial wall cultures (NAwC) were found in 16 patients, three of whom died of multiple-organ failure and sepsis but none of whom had aortic/arterial disruption/hemorrhage. Positive arterial wall cultures (PAwC) were found in 13 patients, seven of whom received short-term, broad-spectrum antibiotics for less than 10 days (PAwC-STA) and six of whom received long-term culture-specific antibiotic therapy (intravenous therapy for 6 weeks and oral therapy for 6 months) (PAwC-LTA). Five of seven patients in the PAwC-STA group died of aortic disruption or hemorrhage, one patient had severe hemorrhage caused by disintegration of a saphenous vein patch over the common femoral artery, and one patient had a recurrent aortoenteric fistula. There were 10 episodes of arterial disruption/hemorrhage in those seven patients. All episodes of aortic/arterial disruption/hemorrhage occurred in the PAwC-STA subgroup (seven of seven patients) and none occurred in the PAwC-LTA subgroup (none of six patients) (0.005 less than p less than 0.001). The incidence of aortic/arterial disruption/hemorrhage was significantly different between overall PAwC (7 of 13 patients) vs NAwC (none of 16 patients) (0.005 less than p less than 0.001) and NAwC-STA (none of 16 patients) vs PAwC-STA (seven of seven patients) (0.001 less than p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

This prospective study examined microbiologic features of arterial tissue and pharmacokinetics and bioactivity of cefamandole and cefazolin in patients undergoing elective primary prosthetic aortoiliofemoral/infrainguinal reconstruction. Double-blind, randomized, perioperative prophylaxis (1 gm intravenously every 6 hours for nine doses) with cefamandole or cefazolin was administered to 47 patients. Specimens of blood serum, subcutaneous fat, thrombus, atheroma, and arterial wall were obtained for culture and minimal inhibitory concentration and drug level analysis by high-pressure liquid chromatography. The serum half-life (hr +/- SEM) was 1.43 +/- 0.36 for cefamandole and 2.22 +/- 0.40 for cefazolin. Over the first 2 hours of surgery and for all time intervals combined, the serum concentration of cefazolin was significantly higher (p less than 0.025) than cefamandole. Irrespective of sampling time, the tissue concentration of cefazolin was significantly greater (p less than 0.005) than cefamandole. Positive arterial tissue cultures were obtained in 12 of 29 patients (41.4%) from 23 of 116 (19.8%) arterial tissue specimens. Coagulase-negative Staphylococcus was the predominant isolate, 64 of 93 (68.8%). Twenty-five of the 51 coagulase-negative staphylocci tested (49%) were slime-producers. During surgery, the arterial tissue concentration of cefamandole fell below the geometric mean minimal inhibitory concentration against all organisms combined, and against S. aureus (with the highest minimal inhibitory concentration of the prevalent isolates), significantly more often than the concentration of cefazolin. The data show that a significant number of primary elective aortoiliofemoral/infrainguinal reconstructions are associated with positive arterial tissue cultures, which represent a potential source of graft infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcutaneous oxygen and carbon dioxide pressure (PO2 and PCO2) foot monitoring was compared with ankle Doppler-derived systolic pressure regarding their respective abilities to discriminate the severity of limb ischemia before vascular reconstruction and to predict surgical outcome early in the postoperative period. Transcutaneous PO2 (tcPCO2), foot-chest tcPO2 index, transcutaneous PCO2 (tcPCO2), foot tcPO2/tcPCO2 index (tcPO2/tcPCO2), ankle Doppler systolic pressure (AP), and ankle-brachial pressure index (ABI) were determined in 89 revascularized limbs. The measurement of tcPO2 and foot-chest tcPO2 was found to be more sensitive to degrees of severity of limb ischemia and more closely associated with the outcome of revascularization than AP and ABI. TcPCO2 and tcPO2/tcPCO2 were not useful in assessment of the vascular patient undergoing reconstructive surgery. Before operation, tcPO2 less than or equal to 22 torr and foot-chest tcPO2 less than or equal to 0.46 indicate severe limb ischemia requiring urgent revascularization. After operation, tcPO2 less than or equal to 22 torr and foot-chest tcPO2 index less than or equal to 0.53 indicate that revascularization is likely to fail. We conclude that tcPO2 monitoring, as a metabolic test of actual tissue perfusion, is a more reliable indicator of preoperative limb ischemia and postoperative outcome of revascularization than hemodynamic, Doppler-derived pressure tests.

A short-term canine model of lower extremity venous hypertension was created to study the hemodynamics of crossfemoral venous bypass grafts (CFB). Specifically, the hemodynamic effects of bypass conduit diameter and adjunctive arteriovenous fistulas (AVFs) were investigated. Unilateral hind limb venous hypertension was produced by iliofemoral venous ligation in six groups of five greyhounds each. Group I had venous ligation alone. CFBs were constructed in the remaining five groups: group II, 3 mm bypass conduit alone; group III, 3 mm bypass plus sequential AVF; group IV, 3 mm bypass plus caudad AVF; group V, 3 mm bypass plus cephalad AVF; group VI, 6 mm bypass conduit alone. Venous hypertension was significantly reduced by CFB (group II, p less than 0.025; group VI, p less than 0.001); increasing the diameter of the bypass conduit from 3 to 6 mm produced significantly greater graft flow (p less than 0.05), while completely relieving venous hypertension. Addition of adjunctive AVFs significantly augmented graft flow (p less than 0.001) but tended to aggravate ipsilateral venous hypertension (group III, p less than 0.01; group IV increase, NSS; group V, p less than 0.001). During the 4 hours of pressure monitoring, venous hypertension diminished significantly (p less than 0.05) with the sequential AVF but not with the other AVF. We conclude that (1) AVFs may be required for adequate graft flow if a small-diameter (3 mm) bypass conduit is used to relieve venous hypertension; (2) adjunctive AVFs aggravate venous hypertension; (3) sequential AVFs seem to be the most hemodynamically efficacious; (4) AVFs may not be necessary if a large, isodiametric (6 mm) conduit is used.