Search

Background: Dislocation injuries of the glenohumeral joint are common in the general public and generally are corrected without complication. One serious complication with shoulder dislocations, or the subsequent reduction, is a lesion to the axillary artery. This specific complication is most frequently seen in the elderly population, where vascular structures have become less flexible. Also, these injuries are most common in association with anterior dislocations of the shoulder. Objectives: To bring awareness to the possibility of axillary artery injury with inferior dislocation of the shoulder, the treatment options, and a review. Case Report: We report a 15-year-old male athlete who inferiorly dislocated his shoulder during wrestling practice. The injury was reduced at the scene with manual traction and the patient was transferred to our clinic for evaluation. The patient was determined to have a pseudoaneurysm of the axillary artery, and the history and treatment of the illness are presented. Conclusion: Axillary artery injuries secondary to shoulder dislocations are rare, especially in the young athlete, and proper recognition and treatment offer patients a full recovery.

Background. The aim of this study was to investigate surgical indications and the long-term outcomes of aortoliofemoral reconstructions in adults younger than 45 years. Methods. Between 1973 and 1990, 1256 patients underwent infrarenal abdominal aortic reconstruction for aortoiliofemoral occlusive disease. Sixty-eight (5.4%) patients (group 1) were less than 45 years old and form the basis of the analysis. They were retrospectively compared with two additional groups of patients 45 years and older selected from the entire series. Patients in group 2 (n = 100) were randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcomes. Patients in group 3 (n = 70) were matched with those in group 1 for gender, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcomes of aortoiliofemoral reconstructions. Results. Postoperative mortality rates (1.5%, 4%, and 4.3% for groups 1, 2, and 3, respectively) and major complication rates (4.4%, 7%, and 7.1% for groups 1, 2, and 3, respectively) were comparable among the three groups. Ten-year secondary patency rates were 84.6%, 70.6%, and 80.3%, for groups 1, 2, and 3, respectively (p = not significant). Ten-year limb salvage rates were 86.9%, 78.2%, and 80.6%, for groups 1, 2, and 3, respectively (p = not significant). During follow-up a significantly higher percentage of myocardial infarction was recorded in group 1 as compared with group 2 (p < 0.03) and group 3 (p < 0.04). The 10-year survival rate for group 1 was significantly lower than that of group 2 (29.0% versus 46.9%; p < 0.005). Conclusions. Aortoliofemoral reconstruction in patients younger than 45 years is a safe procedure with low operative risks and good long-term results in patency and limb salvage rates. However, life expectancy is poor because of the high incidence of deaths related to coronary artery disease.

Purpose: The aim of the study was to investigate surgical indication and long-term outcome of carotid endarterectomy (CE) in young adults.Methods: Between 1973 and 1990, 1693 patients underwent CE. Forty-nine patients (group 1) 35 to 45 years of age who had carotid artery stenosis greater than 70%, formed the basis for the analysis. They were compared with two additional groups of patients older than 45 years of age selected from the entire series. Group 2 was randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcome. Group 3 was matched with patients in group 1 for sex, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcome of CE.Results: Postoperative mortality, cerebrovascular accidents, and cardiac complications in patients of group 1 (2%, 2%, and 2%, respectively) were similar to those of the other groups ( p = NS). During the follow-up (76.7 ± 3.6 months; range, 1 to 120 months) the incidence of strokes and transient ischemic attacks in group 1 was lower than in group 2 ( p < 0.05) but similar to group 3 ( p = NS). Ten-year disease-free intervals were 75.7%, 58.7%, and 77.6%, respectively, for groups 1, 2, and 3. Mortality rate unrelated to cerebrovascular disease was similar between group 1 and group 3 ( p = NS) but was higher in group 1 than in group 2 ( p < 0.02). Ten-year survival rates were 46.1%, 71.7%, and 55.5%, respectively, for group 1, 2, and 3.Conclusions: CE in patients younger than 45 years of age is a safe procedure with low operative risks and good disease-free intervals. However, life expectancy is poor because of the high incidence of deaths resulting from complications of atherosclerosis.(J Vasc Surg 1997;25:464-70.)

Recurrence or persistence of neurologic symptoms after surgical treatment of patients with thoracic outlet syndrome (TOS) are reported to be as high as 25%. To identify factors affecting the long-term outcome of surgical treatment of patients with TOS, we reviewed our 20-year experience.One hundred thirty-four transaxillary first rib resections were performed on 118 patients (43 men, 75 women, mean age 38 +/- 13 years). Eighty-three operations (61.9%) were undertaken to relieve symptoms resulting from compression of the lower roots of the brachial plexus, 37 (27.6%) for compression of both lower and upper roots, and 14 (10.5%) for lower root and vascular symptoms. All patients underwent a transaxillary extraperiosteal first rib resection with transection of the scalene muscles. In 73 cases (54.5%) a resection of the anterior scalene muscle was also performed. A cervical rib was removed in 28 cases (20.1%), and anomalous fibrous bands adjacent to the neurovascular bundle were resected in 41 cases (30.6%).No major complications were observed. Of 105 patients (118 procedures) followed up (mean follow-up, 99 +/- 72 months), good to excellent results were obtained in 96 cases (81.4%) and fair to poor results were recorded in 22 cases (18.6%). The presence of a long posterior first rib stump, measured from the chest x ray films, was the strongest determinant of the long-term results among the variables examined (p0.0001). Reoperation, consisting of neurolysis and resection of the stump, was performed in 16 patients. The results were excellent in all cases at a mean follow-up of 66 +/- 46 months. Primary and secondary 10-year, actuarial freedom rates from recurrent symptoms were 80.9% and 93.1%, respectively.Our results suggest that the long-term outcome after surgery for TOS was strongly influenced by the extent of the first rib resection.

A case of intrapericardial giant lymph node hyperplasia (localized hyaline-vascular variant of Castleman's disease) is reported. The large tumor was successfully removed, and at a twelve-year follow-up there are no signs of recurrence. This is the first case reported in the literature of an intrapericardial Castleman's disease localization. Embryologic, surgical, and prognostic implications of this finding are briefly discussed.

Early results of laser-assisted balloon angioplasty (LABA) and peripheral directional atherectomy (PDA) are encouraging. The true value of these procedures has remained in doubt, however, because of the absence of data on long-term objective patency rates.From August 1988 through October 1993, LABA and PDA were performed on 151 limbs of 124 patients. Presenting symptoms were mild-to-severe claudication in 128 limbs (63 LABA, 65 PDA) and rest pain or necrosis in 23 (7 LABA, 16 PDA). Seventy-seven percent of the atherosclerotic lesions were localized in the iliofemoral tract (77% LABA, 76% PDA). Seventy limbs were treated with LABA and 81 with PDA.Initial hemodynamic and arteriographic success was achieved in 46 LABA limbs (66%) and 75 PDA limbs (93%) (P0.002). Mean follow-up was 16 +/- 2 months after LABA and 18 +/- 1 months after PDA. During this time, 32 failures were recorded in limbs treated with LABA, and 29 in limbs treated with PDA. The patency rate at 40 months was 23% in the LABA group and 45% in the PDA group (P0.005). Patency rates were not affected by the length or site of the arterial lesion or the runoff score.PDA had a better long-term patency rate than LABA, but long-term results were dismal with both techniques. PDA appears to have a limited role and LABA no role in the treatment of lower extremity occlusive disease.

From April, 1990, to April, 1992, peripheral atherectomy using a Simpson AtheroCath was performed in 46 patients (56 limbs) with a total of 106 lesions. There were 100 stenoses (74 eccentric, 26 concentric) and 6 occlusions. Success was achieved in 103/106 (97%) procedures (97 stenoses and 6 occlusions), reducing the lesion to < 35% (stenoses: 81±13% to 22±9%, p < 0.0001, and the occlusions : 100% to 16±8%; p < 0.0001). Ankle/brachial index (ABI) improved from 0.58±0.17 to 0.85 ± 0.22 (p < 0.0001). Clinical success was achieved in 42 patients (91%). Complications occurred in 6 patients (13%): groin hematoma in 5, and in 1, acute occlusion of the femoral artery with distal embolization. There were 13 hemodynamic failures in 11 patients (28%) with an ABI reduction of more than 0.15 with respect to the maximum early postoperative level, over a mean follow-up of 15.1 months. Failure of the procedure was confirmed by arteriography in only 4 cases. Cumulative eighteen-month patency rates were 60% using arteriographic assessment and 44% for hemodynamic assessment (p < 0.025). Patency rates were 56% for the patients with a runoff score ranging between 1 and 5 and 17% with a score > 5 (p < 0.0025). A reduction of ABI during follow-up is not a true indicator of procedural failure, but it correlates with possible progression of distal disease. Evaluation of preoperative runoff may be used as a prognostic indicator.

An axillodistal abdominal aorta bypass graft is proposed as an alterative procedure for revascularization of the lower limbs when intraabdominal and intrathoracic approaches are not feasible. This simple and safe procedure is proposed instead of the axillobifemoral bypass graft for the treatment of selected patients with abdominal aortic occlusive or aneurysmal disease and aortic graft infection. A case of a patient who underwent axilloabdominal aortic grafting because of a ruptured infrarenal abdominal aortic aneurysm, combined with severe chronic obstructive pulmonary disease, is reported.

A case of a popliteal aneurysm presenting as a deep vein thrombosis of the lower extremity is reported. Venous insufficiency symptoms, like presenting symptoms of a popliteal artery aneurysm, are an uncommon occurrence but often cause a wrong or delayed diagnosis with severe consequences for limb salvage. The importance of an accurate diagnostic study in any patient with a suspected deep vein thrombosis is emphasized in this report.

Leiomyosarcoma of the inferior vena cava is a rare and potentially curable tumor. Uncertainty about the results of treatment derives from lack of a large series in the same center and of a long-term follow-up of the published cases. A review of the world literature from 1871 to 1989 allowed us to collect information on 141 patients with inferior vena cava leiomyosarcoma to which our three cases have to be added. The tumor arose from the lower segment of the inferior vena cava (infrarenal portion) in 49 patients, from the middle segment (from the renal veins to the hepatic veins) in 59, and from the upper segment (from the hepatic veins to the right atrium) in 34 patients. Complete clinical, pathologic, and therapeutic data and up-to-date follow-up have been obtained through personal correspondence with several authors. All data have been examined with both univariate and multivariate analyses as predictive factors for outcome. Variables, associated with an increased risk of death from disease, included the involvement of inferior vena cava upper segment and a high-grade tumor. Patients who underwent a radical resection of the tumor (82 patients, 56.9%) had a significantly better survival (27.9% and 14.2%, 5- and 10-year survival rates, respectively). Of these patients, those with tumor of the inferior vena cava middle segment fared better than those with lower segment tumor (5- and 10-year survival rates were 48.3% and 34.4%, respectively, for middle segment tumor and 9.3% and 0.0% for lower segment tumor). Variables associated with a good outcome and longer survival were the presence of abdominal pain and the absence of a palpable abdominal mass. Despite the high rate of recurrence (52.4% of patients undergoing radical operation; median time, 25 months), radical resection of inferior vena cava leiomyosarcoma is the only chance for a long-term cure. An earlier and more accurate preoperative diagnosis, by means of modern diagnostic techniques (echography, CT scanning, magnetic resonance imaging) will allow a higher rate of radical resection to be performed with an increase in patient survival.

In order to determine factors influencing operative and long-term patency of bypass grafting for upper extremity ischemia, a fifteen-year experience with 39 bypass grafts was reviewed. Etiology of the lesions included atherosclerosis in 17 limbs, thoracic outlet syndrome in 7 cases, violent or iatrogenic trauma in 12 cases, and arteritis in 3. Primary lesions affected the innominate, subclavian, axillary, and brachial artery in 2, 19, 8, and 10 cases respectively. All patients had a complete follow up (mean seventy-one ± forty-four months). The thirty- day, one-year, and five-year patency rates were 92%, 81%, and 78%, respec tively. Indications for operation and type of onset of ischemic symptoms significantly influenced graft patency (p

From January, 1973, to December, 1987, 63 arterial revascularization procedures were performed in 50 pa tients suffering from brachial artery injuries following cardiac catheteriza tion. There were 15 occlusive compli cations (30%) after the primary attempt to revascularize the damaged brachial artery. Thrombectomy asso ciated with a simple repair of the arte rial cutdown (Type IA) led to 8 compli cations of 9 procedures performed. Technical details of repair of the dam aged artery—debridement, venous patch graft, resection, end-to-end anastomosis, and venous bypass inter position—were found to be important and led to long-term patency.

Sealed rupture of abdominal aortic aneurysms, even if uncommon, deserves particular attention for the possibility of misdiagnosis and for the deleterious effects of such a misdiagnosis. Sixteen patients (mean age 72 years; range 65 to 84 years) with chronic sealed rupture of abdominal aortic aneurysms are reported. Two patients had acute rupture of the aneurysm, and at operation chronic contained rupture was found along with the recent hemorrhage. One patient died after surgery. The remaining patients underwent successful resection with long-term survival and regression of symptoms. Consideration of sealed abdominal aortic aneurysm rupture should be included when examining elderly patients with history of unexplained back pain or femoral neuropathy. Computed tomography is a useful aid in the diagnosis of sealed rupture. Ultrasonography is less accurate; in three patients ultrasonography failed to diagnose the presence of the rupture. (J VASC SURG 1990;11:430-5.)

Oncostatin M is a member of the IL-6 family of cytokines that is primarily known for its effects on cell growth. Endothelial cells have an abundance of receptors for oncostatin M, and may be its primary target. We determined if oncostatin M induces a key endothelial cell function, initiation of the inflammatory response. We found that subcutaneous injection of oncostatin M in mice caused an acute inflammatory reaction. Oncostatin M in vitro stimulated: (a) polymorphonuclear leukocyte (PMN) transmigration through confluent monolayers of primary human endothelial cells; (b) biphasic PMN adhesion through rapid P-selectin expression, and delayed adhesion mediated by E-selectin synthesis; (c) intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 accumulation; and (d) the expression of PMN activators IL-6, epithelial neutrophil activating peptide-78, growth-related cytokine alpha and growth-related cytokine beta without concomitant IL-8 synthesis. The nature of the response to oncostatin M varied with concentration, suggesting high and low affinity oncostatin M receptors independently stimulated specific responses. Immunohistochemistry showed that macrophage-like cells infiltrating human aortic aneurysms expressed oncostatin M, so it is present during a chronic inflammatory reaction. Therefore, oncostatin M, but not other IL-6 family members, fulfills Koch's postulates as an inflammatory mediator. Since its effects on endothelial cells differ significantly from established mediators like TNFalpha, it may uniquely contribute to the inflammatory cycle.

Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons.Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure.Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P0.00004 and P0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P0.0006).The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

Aneurysmal dilatation of the femoral artery is a rare condition of uncertain aetiology. Between January 1972 and December 1992, 31 atherosclerotic femoral aneurysms in 22 patients were seen. There were 21 men and 1 woman; mean(s.d.) age was 70.1(10.4) years. Thirteen (42%) femoral aneurysms (group 1) were isolated aneurysms, two being bilateral. Eighteen (58%) were associated with a non-contiguous abdominal aortic aneurysm, four being unilateral and seven bilateral femoral aneurysms (group 2). The mean(s.d.) size of these aneurysms was 4.7(1.5) and 3.5(0.7) cm in groups 1 and 2 respectively (P < 0.01). Of the limbs in group 1, 12 were treated by an interposition bypass. A ruptured profunda femoris artery aneurysm was ligated in one limb as an emergency operation. All patients in group 2 underwent an aortobifemoral graft. There was one operative death. Three early thromboses were observed; two autogenous saphenous vein interposition grafts and one limb of an aortobifemoral. One late thrombosis occurred in an expanded polytetrafluoroethylene graft in group 1. The five-year patency rate was 80% for group 1 and 88.9% for group 2 (P = n.s.). The overall 10-year limb salvage rate was 100%. These findings suggest that isolated femoral aneurysms are larger and more frequently symptomatic than femoral aneurysms associated with an abdominal aortic aneurysm. The association between femoral aneurysm and abdominal aortic aneurysm was found to be higher in patients with bilateral femoral aneurysms compared with those with unilateral lesions (P < 0.05). In the treatment of isolated femoral aneurysms better early results were obtained with expanded polytetrafluoroethylene interposition grafts.

Synthetic grafts are widely used for peripheral arterial reconstructions when autologous veins are not available, but their results have not been satisfactory. Venous allograft may be used as an alternative to synthetic prostheses. The aim of the study was to explore the immunosuppressive efficacy of Cyclosporine A (CyA) as a means of preventing venous allograft failures and rejection. We utilized 56 mongrel dogs. Immunological incompatibility was checked with the skin graft method. Donor inferior vena cava was transplanted into the infrarenal abdominal aorta of recipient animals. One group (group 1, 10 dogs) served as a control and three groups received CyA treatment regimens. Group 2 (10 dogs) received postoperative oral CyA treatment for 30 days. Group 3 (12 dogs) received a vein graft pretreated with a CyA solution without postoperative immunosuppressive therapy. Group 4 (9 dogs) received a vein graft pretreated with a CyA solution and postoperative CyA treatment for 30 days. Allografts were examined at 30 days for patency, aneurysmal dilatation, gross structural changes, inflammatory response, and lymphocytic infiltration. Sex chromatine assessment determined the origin (donor or recipient) of the endothelial cells. The allografts from groups 1 and 3 showed significant aneurysmal dilatation and perivenous inflammation when compared to dogs treated with oral CyA therapy (P0.0002). Moreover allografts treated with CyA therapy had a better-developed venous neointima (P0.009) with less fibrin (P0.02) and thinner medial (P0.0009) with less fibrin (P0.02), and thinner medial (P0.0009) and adventitial layers (P0.02). No significant differences were observed in neointimal thickness among the four groups. Lymphocytic infiltration was greater in the group of animals who did not receive oral CyA therapy (P0.0004). Barr bodies status showed significant differences between oral CyA treated groups and nontreated groups (P0.0003). Oral CyA therapy reduced aneurysmal dilatation and immunological response, promoted the development of a neoendothelium, and preserved the structure of the venous layers. Graft pretreatment with CyA flushing did not have a significant immunosuppressive effect.

Over a 7-month period, a 54-year-old male with poorly-controlled diabetes mellitus, chronic hepatitis C infection, chronic low-back pain, and active intravenous drug abuse developed Methicillinresistant Staphylococcus aureus (MRSA) endocarditis, L1-L2 spondylodisciitis with vertebral osteomyelitis, and a psoas abscess (Figure 1, timeline). He initially presented with pneumonia and persistent MRSA bacteremia (Figure 1, Admission #1), for which he received a prolonged course of vancomycin and linezolid. Few days after completing treatment, he presented with recurrence of fever, generalized weakness, and worsening back pain (Figure 1, Admission #2). During this hospitalization, he was found to have infective endocarditis, L1-L2 spondylodisciitis with vertebral osteomyelitis, and a small psoas abscess. The psoas abscess was deemed too small for percutaneous drainage or surgical debridment. He received one week of gentamicin and five-week course of daptomycin at a long-term nursing facility; he declined further antibiotic therapy and left the nursing facility. One week later, he presented to the infectious disease outpatient clinic for routine follow-up. At this time, his chronic low-back pain remained unchanged and he had no fever. He was hospitalized (Figure 1, Admission #3) after routine blood cultures grew MRSA in four sets (within 24 hours). During this hospitalization, a contrast-enhanced T1 magnetic resonance image (MRI) showed a large psoas abscess (Figure 2, panel A, arrow) extending into L1-L2 vertebral bodies (stars). A transverse view showed epidural extension (Figure 2, panel B, arrowhead) and left kidney displacement by the psoas abscess (arrow). During this period, he underwent catheter drainage of the abscess and received vancomycin and gentamycin. Due to continued infection (persistently positive blood cultures), he underwent L1-L2 vertebrectomy, cord decompression, debridement, and spinal reconstruction. A postoperative lateral radiograph shows T10-L4 posterior internal fixation of the spinal cord (Figure 2, panel C, arrows) and installation of a mechanical distractable interbody device (arrowhead). After a prolonged course of antibiotics, although the patient declined them intermittently, he had resolution of the infection. He was hospitalized multiple times (Figure 1, Admissions #4-6) with worsening back pain and suicide ideation. Although he had no fever and the abscess had resolved on repeated tomographic scanning, he had persistent MRSA bacteremia. During these last three hospitalizations, he received intermittent doses of vancomycin (due to patient declining to receive intravenous antibiotics) and trimethoprim-sulfamethoxazole. He left the institution against medical advice several times and eloped from a long-term nursing facility. During the three months after hospital discharge, the institution attempted to contact him ten times, without success. He is lost to follow-up. A Dreaded Complication of MRSA Infection

The results of 26 carotid-subclavian bypass (CSB) and 17 axillo-axillary bypass (AAB) procedures, performed to treat symptomatic lesions of the proximal subclavian artery, were reviewed. Nine graft failures (seven CSB and two AAB) occurred (mean follow-up: CSB = 60.5 +/- 41 months; AAB = 67.8 +/- 48 months). All CSB graft thromboses were observed in patients with an associated ipsilateral carotid lesion, surgically treated or not (p less than 0.05). Cumulative 5- and 10-year patency rates were 78.3 and 62.9% for the CSB group and 87.9% for the AAB group (N.S.). In patients with an associated ipsilateral carotid lesion, 5- and 10-year patency rates were 66.0% and 40.8% for the CSB group and 100% for the AAB group (p less than 0.05). Both the surgical procedures were safe and effective with excellent results in terms of operative mortality, major morbidity and long-term patency. CSB is the procedure of choice for the treatment of proximal subclavian artery disease for its physiological characteristics and for graft shortness. However AAB must be considered a suitable alternative and preferred when a concomitant ipsilateral carotid lesion is present. Recurrence of carotid stenosis or carotid lesion progression may cause the carotid-subclavian failure.

To determine factors influencing results of operation for proximal brachiocephalic arterial disease, a 16-year review of 74 consecutive patients was undertaken. A total of 62 subclavian, 14 common carotid, 6 innominate, and 2 vertebral arteries were revascularized during 79 procedures. The approach was transthoracic in 12 operations and extrathoracic in 67. Mean follow-up was 57 +/- 45 months. Two patients (2.5%) died of stroke after extrathoracic revascularization of the common carotid artery. Cumulative 5-year and 10-year freedom from neurological events was 81% and 75%, respectively. The best results were obtained with transthoracic procedures, with revascularization of the subclavian artery rather than the common carotid artery, and in operations performed in patients without associated distal carotid disease. In view of the recent progress in operative techniques and postoperative surgical care, the choice between the transthoracic approach and the extrathoracic approach should not be biased; rather, they should remain equal and viable alternatives based on anatomical and clinical features of the individual patients.

During the last fifteen years, we performed a total of 855 aortofemoral re constructions. Fifteen (1.75%) grafts were surgically removed (completely or partially) owing to a severe infection (Szilagyi: Grade 3) at a mean of 66.3 months (SD ± 37.9) after their implantation. Diagnosis was always clinically evident. In 10 patients, the graft was partially removed (one or two limbs). In 3 of the 10, graft infection progressed requiring complete graft removal after a mean of 18.6 days. In the other 5 patients, the graft was removed "in toto" at the time of the first operation. In 9 cases, revascularization was accomplished by means of a "remote" takeoff reconstruction (thoracic aorta or axillary ar tery), whereas in 8 cases (3 recurred) reconstruction was performed with a "local" takeoff reconstruction (stump or aortoiliofemoral arteries). One patient was not revascularized, because the limb was already amputated. Recurrence of infection was higher in the patients treated by partial removal of the graft (p < 0.05), even though the stump sterility was always evaluated by means of intraoperative culture. The mortality of patients with recurrence of infection was 66.6%. Multiple operations of the femoral site were considered a factor in causing aortofemoral graft infection (p < 0.01). Diabetes was not considered a factor in causing infection (p n.s.). Grafts with remote takeoff reconstruction have better long-term results in terms of limb salvage and survival when compared with local takeoff recon struction (p < 0.05).

The records of 125 patients 75 years of age or older with a diagnosis of unruptured abdominal aortic aneurysm were reviewed. Operative mortality was 4.3 percent in 69 patients considered at low risk and 39.8 percent in 13 patients at high risk who underwent aneurysmectomy shortly after diagnosis. Forty-three patients with an asymptomatic abdominal aortic aneurysm initially measuring 3.5 to 6 cm did not undergo aneurysmal resection and were followed for 6 to 72 months (mean 24 months) with serial echography. The mean enlargement rate was 0.48 cm/year. In the 43 patients, resection of the abdominal aortic aneurysm was performed for aneurysmal expansion to greater than 6 cm, development of symptoms, or a sudden change in aneurysmal diameter. Two patients were lost to follow-up, 21 underwent elective resection, aneurysms ruptured in 2, 9 died from other causes, and 9 were alive and asymptomatic at last follow-up. An aggressive surgical approach seems appropriate, even in the asymptomatic elderly patient with a small aneurysm of 4.5 to 6 cm. Serial echographic measurement appears useful in determining which patients with a very small aneurysm of less than 4.5 cm or who are considered to be high risk surgical candidates require elective aneurysmectomy.

A 7-year experience with 90 polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts in the above-knee (AK) position is presented. The 5- and 7-year actuarial patency rate was 58.3%. No statistical difference was found between the patency rate of this series and that of a group of 17 AK and 77 below-knee (BK) femoropopliteal bypass grafts performed during the same period with the autologous saphenous vein (ASV). During the follow-up period (range 6 to 84 months, mean 42 months) a new bypass in a more distal location was required in 20 limbs. The ASV was available in seven of the eight PTFE graft failures and in only one of the 12 ASV failures. The 3-year patency rate of these new groups was 58.3% and 16.7%, respectively (p

Among 486 patients undergoing repair for abdominal aortic aneurysm (AAA) during a 12-year period, 30 (6.2%) had evidence of "inflammatory" AAA. One patient (3%) had acute rupture, and six patients (20%) had chronic contained rupture. Ureteral obstruction was evident in 20% of the patients. In the early period of the study there were two postoperative deaths and operative time and blood loss were significantly increased. In the last period of the study, no attempt was made to separate the duodenum and the ureters from the aneurysm; there was no operative mortality, and operative time and blood loss were similar to that of patients with atherosclerotic aneurysms. In 23 of 100 specimens of atherosclerotic AAA, microscopic findings resembling inflammatory AAA were found. On the basis of our study we conclude the following: (1) Inflammatory AAAs are simply atherosclerotic aneurysms that show an unusual accentuation of the chronic inflammation observed in relation to atherosclerotic aneurysms. (2) Operative technique should be modified to avoid excessive dissection and lysis of ureters and duodenum. (3) Excellent early and late results can be expected with proper surgical technique. (4) The causes of AAA are multiple, and chronic contained rupture of the aneurysm and reactive lymphatic hyperplasia might play a role of greater significance than previously thought. (J Vasc Surg 1989;9:643–50.)

From May 1974 to October 1983, 82 patients with severe bilateral carotid disease had unilateral carotid endarterectomy (CE) on the symptomatic side (group I). The carotid artery contralateral to the endarterectomy was severely stenosed (lumen diameter reduction 51% up to 99%) and it was not repaired for different reasons. Group I patients were compared with 78 patients who had bilateral CE (group II), matched with group I for associated diseases, operative indication, and angiographic findings. In this analysis, only neurologic deficits referable to the contralateral hemisphere were considered. There was a higher incidence of later neurologic deficits in the group I patients; however, this difference was not statistically significant. In group I, the occurrence of late neurologic deficits was statistically correlated to (1) severity of stenosis, (2) presence of large compound ulceration, and (3) history of previous stroke. Stepwise logistic regression analysis identified two groups of patients at higher risk for late neurologic deficits (1) patients with stenosis 75% or greater and large ulceration and (2) patients with stenosis 75% or greater and previous stroke. CE on the asymptomatic contralateral side should be considered in selected patients at high risk for late neurologic events at a surgical center with an established low incidence of perioperative complications. A nonoperative policy with careful follow-up is warranted in the remaining cases. (J VASC SURG 1988;8:453-9.)

A modified technique of profunda femoris artery reconstruction is presented. In case of occlusion of the superficial femoral artery, the proximal segment of this vessel is rolled over the profunda femoris artery as a patch after an endarterectomy has been performed. This technique has been performed in 110 patients (131 limbs) during the last 14 years. Five-year actuarial patency rate (life-table method) was 65.3%. With measurements obtained from nine biplanar angiograms, glass models of three different methods of profunda femoris reconstruction were constructed. The model representing this modified technique of profundaplasty showed less turbulence than the others. The results of this study validate the use of this type of profundaplasty in clinical practice.

The success of aortofemoral reconstruction in patients with superficial femoral artery occlusion depends on the restoration of a satisfactory pulsatile flow to the deep femoral artery. In 18 patients with multilevel disease, widespread involvement of the deep femoral artery, and poor distal outflow, we performed an eversion endarterectomy of the proximal segment of the superficial femoral artery and constructed an end-to-side anastomosis between this segment and the distal deep femoral artery. In 10 patients, the reconstruction was performed after thrombectomy of the occluded aortofemoral graft, and in 8 the two reconstructions were simultaneous. The actuarial patency rate was 93.5 percent at 1 year and 75.2 percent at 5 years. Four late femorodistal bypasses were performed that gave an actuarial limb salvage rate of 68.8 percent at 1 year and 61.6 percent at 5 years. In selected cases, this technique is a valid alternative to an extended profundoplasty or to a femorodistal bypass.

In the past 14 years, 22 patients (25 operated sides), with occlusion of the internal carotid artery (ICA), underwent ipsilateral external carotid artery (ECA) endarterectomy at our institution. Operative indications were amaurosis fugax in 13 sides and nonlateralizing transient ischemic attacks in the remaining 12. There were no operative deaths. One patient suffered a minor stroke after operation. Follow-up ranged from 6 to 110 months (median 36 months). In 16 cases, simple endarterectomy with or without vein patch closure was performed (type I). In two cases the ostium of the ICA was occluded with interrupted sutures after endarterectomy (type II). In the remaining seven cases the ICA was transposed as a patch over the endarterectomized ECA after endarterectomy (type III). All but six patients (six sides) underwent duplex scanning or angiography during follow-up. Four of nine patients with previous nonlateralizing symptoms had persistent symptoms after operation, whereas none of those with previous amaurosis fugax did. Recurrent occlusive disease was more common in type I reconstructions (p less than 0.05). Proper ECA reconstruction results in long-term patency. In the patient with ipsilateral ICA occlusion, transposition of the ICA as a patch over the endarterectomized ECA offers a valid hemodynamic solution. Objective parameters are needed to identify patients with nonlateralizing symptoms who will benefit from operation.

Objective: The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated. Methods: The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome. Results: One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9.8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 ± 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome. Conclusion: The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions. (J Vasc Surg 1999;29:894-901.)

Retroperitoneal descending thoracic aorta-femoral artery bypass was performed in 18 patients over an 11-year period. The reconstruction was carried to both femoral arteries in 12 patients; in the other 6, only a single femoral artery was revascularized. The operative indication in Group 1 (3 patients) was infection of a previous aortoiliac reconstruction; in Group 2 (12 patients), occlusion of a previous aortoiliac reconstruction; and in Group 3 (3 patients), aortoiliac occlusive disease in which a direct transabdominal procedure was considered hazardous. Follow-up ranged from 6 months to 9 years (mean, 40 months). Cumulative patency rate was 96 ± 3.9% at 1 year and 85 ± 8.1% at 5 years. No alterations of serum creatinine and blood urea nitrogen values were recorded seven days and 6 months after operation. Retroperitoneal thoracic aorta-femoral artery bypass is a useful technique for accomplishing lower limb revascularization in patients in whom exposure or availability of the abdominal aorta poses a specific hazard.

Primary neurogenic tumors of the lung are rare. Often, their histologic behavior presents a treatment dilemma. We present a case of benign endobronchial neurilemmoma managed by means of YAG laser resection together with a brief discussion of the management options available for these tumors. (Chest 1989; 95:461)

• In patients with combined aortoiliac and femoropopliteal occlusive disease, severe involvement of the deep femoral artery (DFA) has often been considered an indication for simultaneous aortofemoral and femorodistal bypass grafting. In 73 patients (87 limbs) with multilevel disease, extended DFA reconstruction was performed with aortofemoral bypass. Five-year actuarial patency of the reconstructions and overall five-year actuarial limb salvage were 62.2% and 60.2%, respectively. Of 20 variables tested, four were significantly associated with the functional outcome of the procedures. Multivariate analysis identified two factors as predictive of outcome independently from other variables: preoperative ankle-brachial pressure index and angiographic status of the below-knee popliteal artery. However, in case of reoperation for occluded aortofemoral graft, these factors lost their validity. Extended DFA reconstruction is a valuable and durable procedure able to provide an adequate outflow and distal perfusion. Careful judgment in each clinical situation will aid in selecting a small group of patients in which simultaneous femorodistal bypass is required. (Arch Surg1988;123:1269-1273)

• Generally, either reconstruction of or bypassing the femoropopliteal artery is used in lower-limb ischemia. During the last three years, five patients with advanced aortoiliac atherosclerotic occlusive disease, occlusion of the superficial femoral arteries, and multiple stenotic lesions of the profunda femoris artery underwent aortofemoral bypass, superficial femoral artery eversion endarterectomy, and superficial femoral-profunda femoris artery transposition. Three patients have been followed up to four years with patent grafts. One patient died in the immediate postoperative period of a cerebrovascular accident and another required amputation because of persistent ischemic changes and severe "distal" vessel disease. Revascularization of the profunda is necessary when there is concurrent superficial femoral artery occlusion and stenotic lesions of the profunda femoris artery. Transposition of an endarterectomized superficial femoral artery to distal undiseased profunda femoris artery affords one alternative revascularization procedure in the multisegmental diseased profunda where a long segmental endarterectomy of the profunda femoris artery would be hazardous. (Arch Surg115:1111-1113, 1980)

Routine use of high-quality suture material has often been described as a factor in preventing complications such as false aneurysms, infection, and me chanical failure of implanted gafts. Optimal characteristics for a vascular su ture are to maintain its strength without causing an important "foreign body" reaction. Polypropylene monofilament has both characteristics and successfully replaced braided sutures for many years. A new monofilament suture material, which is made of expanded polytetrafluoroethylene (EPTFE), has recently been introduced. The purpose of the present study was to evaluate this new vascular suture and compare it with the widely and successfully used polypropylene su ture. The authors implanted a total of 20 infrarenal aortic reconstructions in dogs using both sutures to perform each anastomosis. Two dogs were sacrificed after 3, 7, 10, 14, 21, 30, 60, 120, 285, and 360 days. Light and scanning electron microscopy of the anastomotic site was routinely performed in order to compare the two suture materials. Thickness of inflam matory reaction around the sutures was measured at three different sites of each suture and statistically compared. Inflammatory reaction was minimal for both sutures and no significant difference was noticed by use of the Student's T- test (p=NS). No ingrowth was shown in either suture. EPTFE, in contrast to polypropylene, at scan electron microscopy, showed a nice layer of fibrin sur rounding the suture and a tendency to adapt to mechanical stress by being oval, elliptical, or circular. In the authors' opinion, EPTFE suture is, therefore, a valuable alternative for use in cardiovascular surgery.

The purpose of this study was to determine the factors influencing enlargement rate of small abdominal aortic aneurysms. Fifty-seven high-risk patients with asymptomatic abdominal aortic aneurysms initially measuring 3.5 to 5.9 cm in the largest transverse diameter were followed with serial echographic measurements for 6 to 78 months (mean 24). The mean enlargement rate (MER) and the occurrence of sudden change in size (SCS) for each aneurysm were correlated to 23 variables. MER ranged from 0 to 1.8 cm/year (mean 0.48). During the study period 17 aneurysms showed SCS. The results of univariate analysis indicated that 8 variables were statistically correlated to the degree of MER and 5 to the occurrence of SCS. A multiple regression model was generated by stepwise regression analysis and demonstrated that 2 variables were independent predictors of the degree of MER: (1) the absence of distal arterial occlusive disease and (2) the ratio of the diameter of the aneurysm to that of the aorta (RD). The overall model P value was less than 0.001. A statistically valid multiple regression model to predict the occurrence of SCS was not feasible (P = 1.0). We conclude that the occurrence of SCS of small abdominal aortic aneurysms is often unpredictable and that the RD rather than the value of the aneurysmal diameter per se must be considered in selecting high-risk patients for echographic follow-up.

An experience on the surgical treatment of anastomotic false aneurysms during the last 15 years was reviewed. Fifty-nine were femoral anastomoses complicated by false aneurysm appearance requiring surgical excision. They represented 2.9% of all femoral anastomoses performed, whereas they represented 3.3% when considering reconstruction in which the femoral artery was the distal anastomosis. Reconstructions with distal anastomosis performed on the femoral artery were primarily involved (58 of 59), whereas grafts with "take off" from the femoral artery were rarely affected (p less than 0.05). A higher incidence of false aneurysm formation was demonstrated in hypertensive patients (p less than 0.05) as well as those who previously had femoral thromboendarterectomy (p less than 0.01). Infection was considered a causative factor even if it developed before (6-14 months) false aneurysm appearance. When a false aneurysm was resected, the best hemodynamic reconstruction, to avoid recurrence, was considered a bypass with distal anastomosis performed end-to-end on the femoral artery (p less than 0.05). The surgical treatment of choice was false aneurysm resection and graft interposition. However, a reanastomosis in the presence of small false aneurysms, when technically possible, has been successfully performed. Both treatments allowed good long-term results.

A ten-year review of 1,360 patients undergoing coronary artery bypass grafting (CABG) by the same surgeon was undertaken. Sixty-two patients with symptoms of coronary artery insufficiency underwent carotid endarterectomy prior to or at the time of CABG (Group I). Ninety-seven patients had asymptomatic carotid bruits but did not undergo carotid endarterectomy (Group II). Sixty of these patients were studied by ultrasonic duplex scanning or ocular pneumoplethysmography or both, and hemodynamically significant stenosis was detected in 50 (Group IIa). Group III included 80 patients without carotid artery disease matched with Group II for sex, age, and clinical status. Group IV consisted of 200 patients without carotid artery disease randomly selected from our series. Follow-up ranged from 3 to 120 months (median, 41 months). In patients with proven carotid artery disease (Groups I and IIa), operative mortality was greater than in the patients randomly selected (Group IV) (p less than 0.05) but similar to that in the matched Group III. Late neurological deficits were greater in patients with carotid disease not undergoing carotid endarterectomy (p less than 0.01). Patients with carotid artery disease had lower survival than Group IV patients (p less than 0.01) but similar survival to that in the matched Group III. This study suggests that (1) asymptomatic patients with carotid artery disease who undergo CABG are not at increased risk of perioperative stroke; (2) these same patients are at increased risk of late neurological deficit; and (3) carotid artery disease is an indirect sign of severe associated disease and therefore is associated with increased operative mortality and decreased life expectancy.

To determine the clinical characteristics and factors influencing outcome in patients with atherosclerotic abdominal aortic aneurysms (AAA), 526 patients who underwent aneurysmal resection were retrospectively reviewed: Group I had clinical evidence of atherosclerotic occlusive disease; Group II had no evidence of atherosclerotic occlusive disease. The incidence of ruptured AAA, multiple aneurysms, and a family history of AAA was higher in Group II patients. We concluded that patients with AAA and without atherosclerotic occlusive disease in other areas represent a subgroup with peculiar clinical characteristics. In planning operative treatment and during the follow-up period, it should be kept in mind that Group II patients have a higher incidence of aneurysm rupture; the incidence of late pseudoaneurysm is higher; and there is a greater possibility of aneurysm in other arterial segments. It remains to be seen if the pathogenetic mechanism of AAA formation in Group II patients is different from that in Group I patients.