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The purpose of the SVS is not just to hold an annual meeting, but also to pursue social, financial, and political responsibilities. In addition, the Society leads in research, training, education, and practice (ie, patient care). The current leadership of the SVS is dedicated to preserving the history of the Society. The History Project Work Group will execute the orders of the Society to develop a series of digital videography recorded interviews with leaders in vascular surgery to be made available to our membership. The information collected will form the basis for a book on the history of the SVS.

Objective: The purpose of this study was to define the incidence and treatment of endograft limb stenosis or occlusion (endograft limb dysfunction [ELD]) in a single center with the ANCURE unsupported bifurcated or aortouniiliac endograft by using intraoperative completion angiography and postoperative color duplex ultrasound scanning (CDU)., Methods: Sixty-seven endografts (58 bifurcated, 9 uniiliac) were implanted between February 1996 and July 2000. Intraoperative completion aortography was performed in every patient. Postoperative assessment of the endograft consisted of CDU and computed tomography scanning and kidney, ureter and bladder radiographs within 7 days of implantation, at 3 and 6 months after the operation, and every 6 months thereafter., Results: At the time of endograft implantation, widely patent normal-appearing endograft limbs were revealed by means of the initial completion angiogram in 58 of 67 patients (group 1). ELD subsequently developed in seven of these 58 patients (13.4%). The results of the completion angiogram were not normal in the remaining nine patients (group 2), leading to the deployment of a self-expanding stent within the endograft limbs. The results of subsequent angiography were normal. No ELD has occurred in any patient in group 2 to date. The primary assisted patency rate at 30 months was 88% +/- 5.2% for group 1 versus 100% +/- 0% for group 2 (P = not significant, Log-rank test). Postoperative ELD occurred in seven patients (10.4%). Endovascular graft thrombosis occurred in three patients (3 endograft limbs). In each case, an endovascular approach was attempted; however, the guidewire would not traverse the occluded endovascular graft limb. Revascularization was accomplished by means of femorofemoral bypass grafting. Endovascular graft stenosis occurred in four patients (4 endograft limbs). Three patients with bifurcated endografts and limb stenosis who had no symptoms diagnosed by means of CDU were successfully treated by means of balloon angioplasty with self-expanding stent implantation, and the endograft limbs remained patent at 3, 5, and 26 months follow-up. The remaining patient who had an aortouniiliac endograft with recurrent severe stenoses underwent endograft explantation and aortobifemoral bypass grafting. The overall incidence of ELD during or after endovascular abdominal aortic aneurysm repair was 23.8% (16 of 67 patients)., Conclusion: Unsupported endografts are at risk for developing ELD. The use of stents for limb support at the time of the initial endograft implantation may prevent subsequent ELD and bears further study. Endograft limb occlusion usually presents with acute severe ischemic symptoms, and the failure of operative thrombectomy necessitates femorofemoral artery bypass grafting. Endograft limb stenosis is identified by means of CDU surveillance in the postoperative period. Prompt treatment with percutaneous transluminal angioplasty/stent yields satisfactory primary assisted patency. Intraoperative intravenous ultrasound scanning, oblique angiograms, pressure gradients, and completion angiography may be necessary to detect and treat ELD.

The incidence rate of treated end-stage renal disease in the united states is 180 per million and continues to rise at a rate of 7.8% per year. Arteriovenous hemodialysis access (AV access) creation and maintenance are two of the most difficult issues associated with the management of patients on hemodialysis. The 1-year complication rate of a primary prosthetic AV access for hemodialysis ranges from 33% to 99%. Various investigators report on patency and complications of AV access. However, it is rather difficult to compare outcomes because of the wide variety of access materials, configurations, locations, risk factors, and quality of inflow and outflow vessels. Although there have been reporting standards for dialysis access endovascular interventions and for central venous access placement, standards regarding surgical access placement and its revision are lacking. The "Dialysis Outcome Quality Initiative," published by the National Kidney Foundation, provides recommendations for optimal clinical practices aimed at improving dialysis outcome and patient survival. This reporting standards document is not meant to be a "practice guidelines" or "best practices" document. Rather, the purpose of this document is to provide standardized definitions related to AV access procedures and to recommend reporting standards for patency and complications, to be used by surgeons, nephrologists, and interventional radiologists, that will permit meaningful comparisons among AV access procedures. The terms, definitions, and categories featured in this article have been approved by the Committee on Reporting Standards of the Society for Vascular Surgery and the American Association for Vascular Surgery and should be observed in preparing manuscripts on AV accesses for submission to the Journal Of Vascular Surgery.

Purpose: The purpose of this study was the demonstration of the value of color duplex ultrasound (CDU) scanning in the detection of type I endoleak (T1EL) and type II endoleak (T2EL), the correlation of Doppler scan waveform pattern to endoleak persistence or seal, and the description of the natural history of endoleak., Methods: The study was a retrospective review of 83 patients who underwent periodic CDU scan and computed tomographic (CT) scan surveillance of the endograft and aneurysm sac after insertion of an aortic endograft for abdominal aortic aneurysm (AAA). Forty-one patients (49%) with an endoleak at anytime in the follow-up period form the basis of this report., Results: T1EL was detected in all five patients with CDU and CT scans. T2EL was detected in 36 patients with CDU scan as compared with 18 patients with CT scan. With CT scan, endoleak was not detected when CDU scan showed no endoleak. Conversely, all CT scan--detected endoleaks were found with CDU scanning. The T2EL source artery was identified with CT scan in seven patients, whereas the source was identified in all 36 patients with CDU scan. Endoleak source did not correlate with outcome (seal or persistence). However, a to/fro Doppler scan waveform pattern was associated with spontaneous T2EL seal in seven of 12 patients, and a monophasic or biphasic waveform was associated with endoleak persistence in 14 of 17 patients (P =.023, with chi(2) test). Thirteen of 36 T2ELs underwent spontaneous seal by 6.2 +/- 2.8 months. T2ELs without increasing AAA diameter were observed. Eight patients with persistent T2EL present for more than 12 months did not undergo treatment. However, two patients underwent T2EL obliteration with coils because of AAA sac enlargement. T1EL of the distal attachment site was the initial endoleak identified in five patients, but seven patients harboring T2ELs had subsequent T1ELs develop. For the entire 83 patients, the combined T1EL and T2EL prevalence rate was 20% of patients at a 6-month follow-up period, but this rate increased to 50% after 24 months. The incidence rate of newly detected endoleaks and of spontaneous sealing was 24.4% at 12 months and 12.5% in longer-term follow-up period., Conclusion: CDU scan is effective in the identification of the type of endoleak, the delineation of the vessel involved, and the hemodynamic information not available with any other testing method. Endoleaks have a dynamic natural history characterized by a variable onset with changing branch vessel involvement and spectral flow patterns. Periodic long-term endograft surveillance with CDU scanning is necessary for following existing endoleaks and for detecting new ones. Corroboration of these findings in larger multicenter prospective trials will be needed to determine whether CDU scan analysis of endoleaks would be predictive of long-term success in endovascular AAA repair.

Purpose: The purpose of this study was to compare the accuracy of a color duplex ultrasound scan (CDU) to a computerized axial tomography scan (CT) in the diagnosis of endoleaks after stent graft repair of abdominal aortic aneurysms., Methods: The Endovascular Aneurysm Clinical Trial Core Laboratory records were reviewed from 117 concurrent CDU and CT studies that were performed in 79 patients who were implanted with the Endovascular Technologies stent graft device between December 1995 and January 1997. All of the studies were interpreted by the Core Laboratory as having the presence or the absence of an endoleak or as being indeterminate because of technical factors. Of the 117 videotaped CDU studies available for reexamination, 100 were reassessed for technical adequacy on the basis of the following criteria: a satisfactory imaging of the aneurysm sac and of the stent graft with gray scale, and both color and spectral Doppler scan evaluation for endoleak outside the endograft and within the aneurysm sac., Results: Of the 117 studies, 103 CDUs (88%) and 114 CTs (97%) were recorded as having the presence or the absence of an endoleak and 14 CDUs (12%) and 3 CTs (3%) were indeterminate. For the studies that were recorded to have the presence or the absence of an endoleak, the sensitivity, the specificity, the positive and the negative predictive values, and the accuracy of CDUs as compared with CTs were 97%, 74%, 66%, 98%, and 82%, respectively. Of the 100 CDU videotaped studies available for review, the following results were seen: (1) 93 CDUs had satisfactory B-mode images, (2) 76 had satisfactory color Doppler scan images to evaluate for endoleaks, (3) 55 had color Doppler scan assessment of the entire abdominal aortic aneurysm sac for endoleak, and (4) 27 had spectral Doppler scan waveform confirmation of suspected endoleaks. Only 19 CDU studies (19%) with all 4 criteria for complete assessment of endoleak were performed., Conclusion: Although most of the CDU studies were technically suboptimal, the CDUs reliably identified endoleaks with an excellent sensitivity and a negative predictive value as compared with CT scans.

Purpose: To determine the long-term outcome and prognostic factors after early infrainguinal graft failure (< 30 days)., Methods: Retrospective analysis of limb salvage data, patency data, and prognostic risk factors in 112 new infrainguinal bypass grafts from 1985 to 1995 that occluded within 30 days of operation., Result: Thirty-six femoropopliteal and 76 femorotibial/femoropedal arterial bypass ("index") procedures were performed for rest pain (50%), tissue loss (31%), or disabling claudication (19%). In 103 patients, an immediate additional revascularization ("takeback") procedure was performed at the time of early graft failure. Life table analysis of the takeback procedures for threatened limbs (n = 84) revealed limb salvage rates of 74%, 54%, 40%, and 31% at 1 month, 1 year, 3 years, and 5 years, respectively. The 1-month limb salvage rate (threatened limbs) was 12% (1 of 8) in patients who were not taken back for revascularization and 33% (4 of 12) in patients who had undergone more than one takeback procedure within 30 days. The secondary graft patency rates for the takeback procedures (n = 103) were 70%, 37%, 27%, and 23% at 1 month, 1 year, 3 years, and 5 years, respectively. Univariate and life table analysis revealed that patients who were given anticoagulation medication after the index procedure (before graft thrombosis) or patients who had undergone previous ipsilateral leg revascularization had significantly lower rates of limb salvage and graft patency (p < 0.05). The limb salvage rate was also significantly worse in patients who had single-vessel runoff compared with those who had multiple-vessel runoff (p < 0.01). Thrombectomy and revision or complete graft replacement had a better secondary patency rate than thrombectomy alone (p < 0.05). Autogenous vein grafts had better outcome than polytetrafluoroethylene-containing grafts, but statistical significance was not achieved. No significant differences in limb salvage or graft patency rates were found between femoropopliteal versus femorotibial/femoropedal bypass grafting, age, gender, previous inflow surgery, diabetes, hypertension, smoking, or cardiac, renal, or pulmonary disease., Conclusion: The long-term limb salvage and graft patency rates after takeback revascularization procedures for early graft failure are poor. Despite poor outcome, a single takeback procedure appears warranted in all patients. Multiple takeback procedures, however, do not appear to be justified, especially in patients who are given anticoagulation medication after the index bypass procedure, repeat leg bypass procedures, or if there is no potential for graft revision.

Purpose: To determine the effect of primary closure (PC) versus expanded polytetrafluoroethylene patch graft angioplasty (PGA) on the incidence of recurrent stenosis (> 50% lumen diameter narrowing) after carotid endarterectomy (CEA), 87 patients undergoing 100 consecutive CEA were prospectively randomized into two groups., Methods: Forty-four patients underwent 51 PC, and 43 patients underwent 49 PGA. All patients were evaluated after operation by duplex scanning at 1.5, 12, 24, and 36 months. There were no significant differences in the demographic characteristics or operative indications for CEA between the two patient groups. Complete follow-up was achieved in 86% (75/87) of the patients during the 36-month surveillance period., Results: The perioperative permanent neurologic morbidity in the PC and PGA groups was noted to be 4% and 2%, respectively (PC = 2/51 vs PGA = 1/49, p = 0.58). Three additional reversible cerebral ischemic events occurred in the postoperative period (PC = 2/51 vs PGA = 1/49, p = 0.58). Other morbidity included immediate postoperative hemorrhage requiring reexploration (1/51) in the PC group and an infected expanded polytetrafluoroethylene patch requiring removal and replacement with autogenous vein (1/49). Long-term follow-up detected a single patient with significant bilateral restenoses of his primarily closed carotid arteries. None of the patients in the PGA group had restenoses (PC = 2/51 vs 0/49, p = 0.50). In addition, no postoperative dilation of the common or internal carotid arteries or perioperative death was observed., Conclusions: In patients undergoing CEA, these data demonstrate no significant difference in the perioperative morbidity or mortality between PC and PGA. Use of the patch did not engender patients to patch rupture or aneurysmal degeneration as previously described with vein patch angioplasty procedures. This series supports effective use of either technique to achieve minimal rates of restenosis.

A 32-year-old man was transferred to our hospital after a 2.0 by 2.5 cm traumatic false aneurysm of the distal extracranial vertebral artery was noted after a stab wound of the posterior side of the neck. To obviate the need for operative exposure of the distal vertebral artery at the base of the skull, we elected to perform duplex-directed manual occlusion of the lesion. Angiography before and after the procedure, as well as 10-month follow-up duplex ultrasonography, demonstrated satisfactory thrombosis of the false aneurysm without evidence of a residual arterial defect. There was no morbidity associated with the procedure. We conclude that duplex-directed manual occlusion, a new technique recently described for the nonoperative management of postcatheterization femoral false aneurysms, can be applied safely and effectively to false aneurysms in other locations in which the risks and technical difficulties of operative repair render surgery less desirable.

Purpose: During the past 14 months we conducted a prospective clinical trial to evaluate the efficacy of duplex-directed manual occlusion (DDMO) of iatrogenic femoral false aneurysms (FFAs) as an alternative to standard operative management., Methods: In all cases DDMO was performed with real-time color-flow imaging while steady, continuous external pressure was applied manually to the neck of the FFA by an experienced vascular technologist for a period of 10 minutes., Results: Ten of the 11 FFAs treated with DDMO in this series were thrombosed successfully, requiring a mean of 30 minutes of compression per aneurysm (three compressions of 10 minutes each). DDMO was unsuccessful in one patient, whose session was terminated because of severe discomfort as a result of the procedure. All 10 patients with successfully thrombosed FFAs are without recurrence at 1-month follow-up color-flow duplex examination, and there has been no morbidity attributable to DDMO., Conclusions: We conclude that DDMO of postcatheterization FFA can be performed safely and is an inexpensive, effective, nonoperative method of managing such lesions. The precise role of this technique would appear to be as a first-line treatment for uncomplicated iatrogenic FFAs.

Twenty-two patients with intermittent claudication were prospectively enrolled in a 12-week program of supervised, graded treadmill exercise therapy. Severity and distribution of arterial occlusive disease were ascertained by noninvasive determination of segmental lower extremity blood pressures and waveforms. No attempt was made to modify risk factors for atherosclerotic occlusive disease. The exercise-induced reduction of the ankle pressure and its recovery were recorded over time, and the area under this curve, the "ischemic window," represents the severity of the ischemic deficit. Absolute systolic ankle pressure, ankle-brachial index, maximum walking time, claudication pain time, and the ischemic window were measured before and after exercise training in all subjects. Maximum walking time and claudication pain time increased 659% and 846%, respectively, among the 19 patients completing the 12-week program (p = 0.001; p = 0.0002). These patients underwent a mean reduction of 58.7% in the ischemic window after a standardized workload (p less than 0.05), and this correlated with the degree of symptomatic improvement. Absolute ankle pressure and ankle-brachial index were unchanged after exercise training. This study confirms the utility of supervised exercise therapy in the treatment of intermittent claudication. The ischemic window is a useful method for quantifying the ischemic deficit produced by exercise and provides a reproducible means of documenting functional improvement in patients undergoing exercise training.

The clinical, duplex, and angiographic findings in six patients with seven spontaneous extracranial carotid artery dissections are reported. Four dissections resulted in internal carotid artery occlusion. These patients complained of ipsilateral headache followed by contralateral hemiplegia. The other three dissections involved the common carotid artery and resulted in dual (one true and one false) lumens. Two of these dissections were asymptomatic. All dissections were treated nonoperatively with anticoagulant therapy. Neurologic deficits improved or disappeared in all symptomatic patients. On follow-up studies, one of the four internal carotid occlusions completely resolved with normalization of the duplex examination. All three dual lumen dissections remained patent on serial studies. Diagnostic duplex characteristics, both conclusive and supportive, of carotid dissections are described. Duplex scanning is shown to be accurate in diagnosing and ideally suited for serially following spontaneous carotid dissections.

Favorable early results with mechanical angioplasty devices and laser-assisted balloon angioplasty have resulted in aggressive marketing and a rapid increase in the use of these devices for the treatment of femoropopliteal occlusive disease. Recent reports, however, have questioned the durability of these less invasive procedures. Since 1986 we have been involved in the clinical investigation of the Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty. One hundred two balloon angioplasty procedures assisted by the Nd:YAG laser (n = 56) and the Kensey dynamic angioplasty instrument (n = 46) were performed for the treatment of femoropopliteal occlusive lesions. Both Kensey dynamic angioplasty instrument and laser-assisted balloon angioplasty groups were similar with regard to age, operative indication, preoperative ankle-brachial index, lesion length, and distal runoff. Mean follow-up was 19 months in the Kensey dynamic angioplasty instrument group and 15 months in the laser-assisted balloon angioplasty group. Technically successful recanalization was achieved in 67% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 82% of laser-assisted balloon angioplasty procedures. Early hemodynamic and clinical improvement was obtained in 59% of Kensey dynamic angioplasty instrument-assisted balloon angioplasty procedures and 57% of laser-assisted balloon angioplasty procedures. Two-year clinical success by life-table analysis was 37% in the Kensey dynamic angioplasty instrument group and 19% in the laser-assisted balloon angioplasty group. The level of subsequent surgical revascularization was not altered in any patient by Kensey dynamic angioplasty instrument-assisted balloon angioplasty or laser-assisted balloon angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

We retrospectively reviewed the results of 108 consecutive femorocrural bypasses performed with prosthetic/autogenous composite graft material and compared these with the results of 57 crural bypasses using greater saphenous vein by the in situ technique. Indication for operation in all cases was the salvage of an otherwise imminently threatened limb. Polytetrafluoroethylene-composite grafts (n = 87) and human umbilical vein-composite grafts (n = 21) were placed only in patients lacking suitable autogenous material for in-line reconstruction. Patient groups were similar with respect to mean age, prevalence of arterial disease risk factors, quality of the distal runoff, and location of the distal anastomosis. Cumulative patency rates at 1 year by life-table analysis were 81.9%, 34.6%, and 12.1% for the in situ, polytetrafluoroethylene-composite and human umbilical vein-composite groups, respectively. At 2 years these were 63.9%, 29.9%, and 6.0%, respectively (p less than 0.025). Cumulative limb salvage at 1 year was 70.6%, 62.3%, and 32.7%, respectively. Wound-related complications occurred in 52.4% of human umbilical vein-composite, 38.6% of in situ, and 18.3% of polytetrafluoroethylene-composite bypasses (p less than 0.05). On the basis of these results, we conclude that femorocrural bypass with polytetrafluoroethylene-composite graft is an acceptable form of distal reconstruction for limb salvage in patients lacking sufficient lengths of autogenous vein. We no longer use human umbilical vein for composite construction.

A diverse terrestial biota inhabited polar latitudes during the Cretacous, 105 to 130 Ma (million years ago), along what is now the southeast coast of Australia This biota, from rocks in the Otway and Strzelecki groups, cnsisted of more than 150 taxa of vertebrates, invertebrates, and plants. Oxygen isotope ratios in diagenetic calcite suggest that mean annual temperatures were most likely less than 5 degrees C, and rings present in the fossil araucarian-podocarp-ginko woods indicate saonality. Southeastern Austalia, thus, seems to have had a cool, seasonal, nontropical climate. Dinosaurs that have been recovered are up to five species and three genera of hypsilophodontids, all of which were endemic, and three species of theropods. The occurrence of Allosaurus sp. and labyrinthodont amphibians, which had become extinct elsewhere in the Jurassic, indicate that isolation may have allowed extended surival of these taxa in Australia. In that dinosaurs coped with high latitude for at least 65 million years [Valaginian to Albian time in Australia and Campanian to Maastrictian time (80 to 65 Ma) in Alaska] suggests that cold and darkness may not have been prime factors bringing about the extinction of dinosaurs and some other groups at the Cretaceous-Tertiary boundary, unless they were prolonged.

During a ten-year period (1969-1980), 106 grafts were implanted in the axillofemoral and axillobifemoral positions. This retrospective study is based on life table analysis of cumulative patency rates in both axillofemoral and axillobifemoral grafts, with and without thrombectomy. Dacron grafts were used exclusively from 1969 to 1979, and PTFE from 1979 to 1980. Cumulative patency for Dacron axillobifemoral grafts was 97 +/- 3% at 32 months (73 +/- 21% at 42 months). Patency in both unilateral and bifemoral grafts was significantly increased by thrombectomy. Dacron and PTFE axillobifemoral graft patency was not significantly different. Perioperative mortality was 8% in a group of patients whose survival rate at four years was only 50 +/- 10% from associated disease. Axillobifemoral grafting presents an alternative to aortoiliac reconstruction in elderly patients with severe associated disease in whom the risk of anatomic bypass is prohibitive.

The Kensey dynamic angioplasty instrument is an atherectomy device approved by the Food and Drug Administration that uses a rotating cam tip housed within a flexible polyurethane catheter to recanalize obstructed and stenotic arteries. Twenty patients with significant femoral arteriosclerotic occlusive disease underwent attempted transluminal endarterectomy of 23 extremities with the Kensey catheter. Significant improvements of superficial femoral artery luminal diameter was achieved in 10 of 13 patients with stenosis and passage of the spinning catheter tip at 60,000 to 90,000 rpm through areas of complete occlusion was successful in 4 of 10 cases. Balloon dilatation was used as an adjunct to increase the diameter of the superficial femoral artery lumen in 11 of 14 successful cases. This preliminary report provides technical data and short-term follow-up of this new innovative vascular tool.

Symptomatic carotid dissection following repair of a proximal aortic arch dissection has been successfully diagnosed by noninvasive ultrasonic duplex scanning. Angiographic confirmation, follow-up examinations by duplex scanner, and conservative management with heparin anticoagulation and tight blood pressure control are discussed. The differing etiologies and potential neurologic complications following aortic root dissection vs. spontaneous cervical carotid dissection are considered with a review of the current literature. Although diagnosis can be achieved through arteriography, the combined modalities of duplex scanning allow evaluation of both anatomic and hemodynamic factors. Conservative therapy may prove the most appropriate mode of management in these neurologically unstable patients.

To provide sequential, quantitative analysis of the cellular events occurring in reversed autogenous vein grafts after implantation and potential modifications of these events, two groups of veins were evaluated. Veins prepared by standard techniques of unmonitored pressure distension with cold heparinized saline solution, tributary ligation adjacent to the wall, and storage at 4 degrees C were morphometrically compared with veins harvested by means of a modified protocol of papaverine irrigation, tributary ligation away from the graft wall, pressure distension to 100 mm Hg with heparinized blood containing papaverine at body temperature, storage in identical solution at 4 degrees C, and implantation while distended. Unilateral jugular veins harvested from dogs with the modified technique (IRJV,N = 9) or standard technique (SRJV,N = 9) were implanted into carotid arteries, retrieved at 30 minutes, 2 days, and 10 days postoperatively along with the contralateral control vein after perfusion fixation in situ, and examined microscopically to quantitate intimal-medial thickness and endothelial damage (denudation and ultrastructural alterations). All IRJVs remained endothelialized, whereas SRJVs had 19% and 40% endothelial denudation at 30 minutes and 2 days, respectively, as well as massive neutrophil, platelet, and monocyte involvement. In contrast, IRJVs had only a modest infiltration of monocytes beginning early after implantation and culminating in their localization beneath endothelial cells; these endothelial cells increased in number during the 10-day period. Although SRJVs exhibited nearly complete reendothelialization over the luminal surface of macrophages by 10 days, endothelial damage was consistently higher than that of IRJVs at all periods and intimal-medial thickness was significantly greater at 10 days (65 +/- 0 vs. 57 +/- 0 micron, respectively; p less than 0.001). These findings suggest that endothelial preservation with improved harvesting techniques inhibits thrombosis and limits wall thickening and also that macrophages may play a protective role by promoting endothelial proliferation.