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Endovascular therapy is first-line treatment for aortoiliac occlusive disease. This shift has altered case volume, patient selection, and risk profile for aortobifemoral bypass (ABF). Given this, we sought to investigate factors influencing morbidity and mortality after ABF in the endovascular era.Data for patients undergoing primary ABF from 2000 to 2017 were queried. Primary endpoints included major complication (unplanned return to the operating room, life-or-limb-threatening complications, and 30-day readmission or death) and long-term survival. Logistic regression and Cox proportional hazard models determined predictors of primary endpoints. Kaplan-Meier analysis estimated patency, freedom from reintervention, and long-term survival.During these 17 years, 256 patients underwent primary ABF. Mean age was 67.9 ± 10.6 years and 51.2% were women. Most had claudication (69.5%); 28.9% had critical ischemia. Sixty-five (25.4%) patients had prior aortoiliac endovascular intervention, 106 (41.4%) required aortic cuff endarterectomy, 111 (43.3%) femoral outflow adjunct, 9 (3.5%) simultaneous lower extremity bypass, and 230 (89.8%) had Trans-Atlantic Inter-Society Consensus D lesions. Concomitant renovisceral revascularization was needed in 42 (16.4%) patients. Thirty-day mortality was 2.7%. Major complication occurred in 92 patients (35.9%). Predictors included prior endovascular intervention (odds ratio [OR], 2.2; 95% confidence interval [CI]: 1.2-4.1; P = 0.01), malignancy (OR, 2.6; 95% CI: 1.3-5.3; P = 0.01), intraoperative complication (OR, 3.3; 95% CI: 1.3-9.2; P = 0.03), operative blood loss, (OR, 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.03), and cuff endarterectomy (OR, 1.8; 95% CI: 1.0-3.1; P = 0.04). Median follow-up was 5.3 years (interquartile range: 7.2 years). Survival at 1, 3, and 5 years was 94%, 90%, and 82% respectively. Primary patency and freedom from reintervention at 5 years were 76% and 79%, respectively. Predictors of late mortality included malignancy (hazard ratio [HR], 2.3; 95% CI: 1.3-3.9; P 0.01), chronic obstructive pulmonary disease (HR, 1.8; 95% CI: 1.1-3.1; P = 0.02), congestive heart failure (HR, 2.3; 95% CI: 1.2-4.3; P = 0.01), Rutherford's class (HR, 1.5; 95% CI: 1.1-2.1; P = 0.01), operative blood loss (HR 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.04) and chronic kidney disease (HR, 2.3; 95% CI: 1.2-4.2; P = 0.01).Although late outcomes after ABF in the contemporary era remain acceptable, major complications are frequent. Operative complexity and prior endovascular revascularization predict complications. Long-term survival is driven by degree of limb ischemia and comorbidities. These should be considered in selection for ABF, potentially modifying approach to improve outcomes.

Despite advancements, aortofemoral bypass (AFB) remains the most durable option for aortoiliac occlusive disease. Although runoff has been shown to be associated with AFB patency, the association of the Society for Vascular Surgery (SVS) thigh runoff scoring system with patency has not been assessed. The aim of the present study was to evaluate the association between the SVS runoff scoring system and limb-based primary patency after AFB.Institutional data for patients undergoing AFB with preoperative runoff imaging available from 2000 to 2017 were queried. Runoff scores were assigned according to the presence of occlusive disease in the superficial femoral artery and profunda femoris artery (minimum, 1; maximum, 10) as described by the 1997 SVS reporting standards for lower extremity ischemia. Limb-based patency was the primary endpoint. Kaplan-Meier analysis was used to compare the long-term limb-based patency and freedom from reintervention between limbs with runoff scores ≥6 and those with runoff scores 6. Propensity score-weighted Cox proportional hazards modeling was used to evaluate the association between a runoff score of ≥6 and primary patency loss, controlling for other factors associated with primary patency.In 161 patients, 316 limbs had undergone revascularization. The mean patient age was 66.7 ± 11.3 years, and 51.6% were women. Most limbs had undergone revascularization for claudication (56.5%). Most (89.4%) had TransAtlantic InterSociety Consensus class D lesions, 27.3% had required suprarenal or higher clamping, and 11.2% had undergone concomitant mesenteric intervention. A femoral outflow adjunct and concurrent lower extremity bypass was required in 41.8% and 2.9% of limbs, respectively. Those with a runoff score of ≥6 had experienced greater rates of 30-day myocardial infarction (11% vs 1%; P = .005), respiratory failure (11% vs 1%; P = .005), and mortality (8% vs 0%; P ≤ .006). The median follow-up period was 4.0 years (interquartile range, 6.5 years). The 1-, 3-, and 5-year primary patency was 94.6% (95% confidence interval [CI], 91.9%-97.3%), 89.2% (95% CI, 85.4%-93.2%), and 81.4% (95% CI, 76.0%-87.1%), respectively. The 5-year primary-assisted patency, secondary patency, and freedom from reintervention were 84.9% (95% CI, 79.7%-90.5%), 91.7% (95% CI, 87.3%-96.3%), and 83.3% (95% CI, 78.3%-88.7%), respectively. Patients with a runoff score of ≥6 had lower primary (log-rank P .01), primary-assisted (P .01), and secondary patency (P = .01). The factors associated with the loss of primary patency included a high runoff score (runoff score of ≥6: hazard ratio [HR], 4.1; 95% CI, 2.1-8.0; P .01), simultaneous mesenteric endarterectomy (HR, 13.5; 95% CI, 1.9-97.8; P = .01), and chronic kidney disease (HR, 4.6; 95% CI, 1.5-14.6; P = .01). Increasing age (HR, 0.94 per year; 95% CI, 0.91-0.97; P .01) and hyperlipidemia (HR, 0.44; 95% CI, 0.23-0.85; P = .01) were protective.The SVS femoral runoff score is an important factor associated with long-term AFB limb patency. Scores of ≥6 portend for worse limb outcomes and a greater incidence of operative complications. The SVS score can be determined from preoperative axial imaging studies and serve as a guide in decision-making and operative planning.

Despite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention.Institutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications.There were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P .01) and aortounifemoral bypass (P .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004).Whereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.

Background: \ud Cancers of Unknown Primary (CUP) are the 3-4th most common causes of cancer death and recent clinical guidelines recommend that patients should be directed to a team dedicated to their care. Our aim was to inform the care of patients diagnosed with CUP during hospital admission.\ud \ud Methods: \ud Descriptive study using hospital admissions (Scottish Morbidity Record 01) linked to cancer registrations (ICD-10 C77-80) and death records from 1998 to 2011 in West of Scotland, UK (population 2.4 m). Cox proportional hazards models were used to assess effects of baseline variables on survival.\ud \ud Results: \ud Seven thousand five hundred ninety nine patients were diagnosed with CUP over the study period, 54.4% female, 67.4% aged ≥ 70 years, 36.7% from the most deprived socio-economic quintile. 71% of all diagnoses were made during a hospital admission, among which 88.6% were emergency presentations and the majority (56.3%) were admitted to general medicine. Median length of stay was 15 days and median survival after admission 33 days. Non-specific morphology, emergency admission, age over 60 years, male sex and admission to geriatric medicine were all associated with poorer survival in adjusted analysis.\ud \ud Conclusions: \ud Patients with a diagnosis of CUP are usually diagnosed during unplanned hospital admissions and have very poor survival. To ensure that patients with CUP are quickly identified and directed to optimal care, increased surveillance and rapid referral pathways will be required.

Objective As branched/fenestrated endografts expand endovascular options for juxtarenal abdominal aortic aneurysms (JAAAs), long-term durability will be compared to that of open JAAA repair, which has not been documented in large contemporary series. The goal of this study was to assess the late clinical and anatomic outcomes after open JAAA repair. Methods From July 2001 to December 2007, 199 patients underwent open elective JAAA repair, as defined by a need for suprarenal clamping. End points included perioperative and late survival, long-term follow-up of renal function, and freedom from graft-related complications. Factors predictive of survival were determined by multivariate analysis. Results The mean patient age was 74 years, 71% were men, and 20% had baseline renal insufficiency (Cr >1.5). Thirty-seven renal artery bypasses, for anatomic necessity or ostial stenosis, were performed in 36 patients. Overall 30-day mortality was 2.5%. Four patients (2.0%) required early dialysis; one patient recovered by discharge. Two additional patients progressed to dialysis over long-term follow-up. There was one graft infection involving one limb of a bifurcated graft. Surveillance imaging was obtained in 101 patients (72% of survivors) at a mean follow-up of 41 ± 28 months. Renal artery occlusion occurred in four patients (3% of imaged renal arteries; one native/three grafts). Two patients (2.0%) had aneurysmal degeneration of the aorta either proximal or distal to the repaired segment, but there were no anastomotic pseudoaneurysms. Remote aneurysms were found in 29 patients (29% of imaged patients), 14 of whom had descending thoracic aneurysm or TAAA. Four patients underwent subsequent thoracic endovascular aneurysm repair (TEVAR). Actuarial survival was 74 ± 3.3% at 5 years. Negative predictors of survival included increasing age at the time of operation (relative risk [RR], 1.05; P = .01), steroid use (RR, 2.20; P = .001), and elevated preoperative creatinine (RR, 1.73; P = .02). Conclusions Open JAAA repair yields excellent long-term anatomic durability and preserves renal function. Perioperative renal insufficiency occurs in 8.5% of patients, but few of them progress to dialysis. Graft-related complications are rare (2% at 40 months); however, axial imaging revealed descending thoracic aneurysms in 14% of imaged patients, making continued surveillance for remote aneurysms prudent. These data provide a benchmark against which fenestrated/branched endovascular aneurysm repair (EVAR) outcomes can be compared.

Objective The role of thoracic endovascular aortic repair (TEVAR) in the management of acute type B aortic dissection remains undefined. Entry tear coverage during the acute phase is an appealing method to treat acute complications, and by inducing false lumen thrombosis, might also prevent late aneurysm formation. This study evaluated structural changes by serial computed tomography (CT) in the thoracic aorta after TEVAR performed for acute complicated aortic dissection. Methods Between August 2005 and October 2007, 33 patients with complicated acute type B aortic dissection were treated with TEVAR (19 from a prospective industry sponsored trial, 14 from our institution). CT images obtained preprocedurally (PP), at 1 month (1M), and 1 year (1Y) were evaluated for each patient. Four patients with no postprocedural imaging were excluded. The largest diameters of the thoracic aorta, dissection true lumen, and false lumen were recorded at each time point. Canges in total aortic and true and false lumen diameters were evaluated using a mixed effect analysis of variance model of repeated measures. Results The average age was 58 years (range, 38-87 years); 26 (81%) were male. Indications for TEVAR included malperfusion syndrome in 17 (53%), refractory hypertension in 14 (44%), impending rupture in 12 (28%), and refractory pain in 14 (44%); 19 (59%) had more than one indication. The average length of aorta covered was 19.5 cm (range, 10-29.3 cm). The maximum aortic diameter decreased over time ( P = .04) and averaged 39.9 (PP), 41.3 (1M), and 34.8 mm (1Y). The true lumen diameter increased over time ( P = .02) and averaged 23.7 (PP), 29.0 (1M), and 31.1 mm (1Y). The false lumen diameter decreased ( P = .046) and averaged 19.5 (PP), 12.1 (1M), and 9.6 mm (1Y). Partial or complete thrombosis of the false lumen along the stented segment of aorta was recorded in 87% (PP), 93% (1M), and 88% (1Y). Conclusions TEVAR of acute complicated aortic dissection appears to promote early aortic remodeling. Nearly 90% of patients maintained at least partial false lumen thrombosis at 1 year. Because continued false lumen patency correlates strongly with late aneurysm formation, such favorable remodeling is considered a surrogate for prevention of late aneurysm, but longer follow-up is required.

To explore possible causes of the poor survival of Scottish lung cancer patients, a retrospective registry-based audit was conducted comparing demography, treatment and survival of 3833 Scottish patients and 2073 from British Columbia (BC). Patients from Scotland were older, had a lower rate of pathological confirmation (74% vs 89%, p

ObjectiveIn multiple comparisons of open vs endovascular (EVAR) repair of abdominal aortic aneurysms, the prior assumption that open repair produced superior durability has been challenged by advocates of EVAR. Although focus on EVAR reintervention has been intense, few contemporary studies document late outcomes after open repair; this was the goal of this study.MethodsFrom January 1994 to December 1998 (chosen to ensure a minimum 5-year follow-up), 540 patients underwent elective open repair. Surveillance imaging (computed tomographic and magnetic resonance imaging scans) was obtained for 152 (57%) of the 269 patients who remained alive at a mean follow-up of 87 months. Study end points included freedom from graft-related interventions and aneurysm-related and overall survival (Kaplan-Meier test); factors predictive of these end points were determined by multivariate analysis.ResultsThe mean age at operation was 73 years. A total of 76% of patients were male; 11% had renal insufficiency (creatinine ≥1.5 mg/dL), and 13% had chronic obstructive pulmonary disease. The aortic cross-clamp position was suprarenal in 135 (25%) patients, and 284 (53%) of patients had bifurcated grafts placed. Operative mortality (30 days) was 3%, and the median length of hospital stay was 7 days. Postoperative complications occurred in 68 (13%) patients. Predictors of postoperative complications included a history of myocardial infarction (hazard ratio [HR], 2.0; P = .01) and renal insufficiency (HR, 2.5; P = .02). The mean follow-up for all patients was 87 months. Actuarial survival was 70.7% ± 2% and 44.3% ± 2.4% at 5 and 10 years, respectively. Negative predictors of long-term survival included advanced age (HR, 1.1; P < .001), history of myocardial infarction (HR, 1.37; P = .02), and renal insufficiency (HR, 1.5; P = .04). Freedom from graft-related reintervention was 98.2% ± 0.8% and 94.3% ± 3.4% at 5 and 10 years, respectively. There were 13 late graft-related complications in 11 (2%) patients (mean follow-up, 7.2 years). Findings included seven anastomotic pseudoaneurysms (five were repaired), four graft limb occlusions, and two graft infections. Aneurysms were identified in noncontiguous arterial segments in 68 (45%) of 152 patients, most of which involved the iliac arteries and required no treatment because of small size. Late aortic aneurysms proximal to the repair were identified in 24% of patients, and 29 (19%) patients had multiple late synchronous aneurysms.ConclusionsOpen repair remains a safe and durable option for the management of abdominal aortic aneurysms, with an excellent associated 10-year survival in patients who undergo operation at 75 years of age or younger. In addition, the freedom from graft-related reintervention is superior to that of EVAR. Finally, continued surveillance after open repair is appropriate and should be directed toward the detection of other aneurysms.

Background and aims: Family history is used extensively to estimate the risk of colorectal cancer but there is considerable potential for recall bias and inaccuracy. Hence we systematically assessed the accuracy of family history reported at interview compared with actual cancer experience in relatives. Methods: Using face to face interviews, we recorded family history from 199 colorectal cancer cases and 133 community controls, totalling 5637 first and second degree relatives (FDRs/SDRs). We linked computerised cancer registry data to interview information to determine the accuracy of family history reporting. Results: Cases substantially underreported colorectal cancer arising both in FDRs (sensitivity 0.566 (95% confidence interval (CI) 0.433, 0.690); specificity 0.990 (95% CI 0.983, 0.994)) and SDRs (sensitivity 0.271 (95% CI 0.166, 0.410); specificity 0.996 (95% CI 0.992, 0.998)). There was no observable difference in accuracy of reporting family history between case and control interviewees. Control subjects similarly underreported colorectal cancer in FDRs (sensitivity 0.529 (95% CI 0.310, 0.738); specificity 0.995 (95% CI 0.989, 0.998)) and SDRs (sensitivity 0.333 (95% CI 0.192, 0.512); specificity 0.995 (95% CI 0.991, 0.995)). To determine practical implications of inaccurate family history, we applied family history criteria before and after record linkage. Only two of five families reported at interview to meet surveillance criteria did so after validation, whereas only two of six families that actually merited surveillance were identified by interview. Conclusions: This study has quantified the inaccuracy of interview in identifying people at risk of colorectal cancer due to a family history. Colorectal cancer was substantially underreported and so family history information should be interpreted with caution. These findings have considerable relevance to identifying patients who merit surveillance colonoscopy and to epidemiological studies.

PurposeThis study was undertaken to assess the results of endovascular aortic aneurysm repair with the Lifepath abdominal aortic aneurysm (AAA) graft system.MethodIn a prospective clinical trial, 23 centers used the Lifepath System balloon-expandable, modular bifurcated stent graft for elective endovascular aortic aneurysm repair. Stent grafts were sized according to computed tomographic angiography–based diameter measurements. All repairs were performed in the operating room through bilateral surgically exposed femoral arteries. Results were assessed with contrast agent–enhanced computed tomography scans and plain abdominal x-ray films at 1, 6, 12, 24, 36, and 48 months postoperatively.ResultsOver 52 months (mean follow-up, 11 months), 227 patients (206 men, 21 women) were enrolled. Technical implant success rate was 98.7%. There were five (2.2%) conversions to open surgery: two emergently because of aortic perforation; to treat refractory endoleak, immediate in one and at 12 months in one; and to replace a device with wireform fractures that had migrated at 12 months, resulting in a proximal endoleak. The perioperative mortality rate was 1.3%. There was one operative death during a secondary procedure to repair perforation of the aorta. There were two perioperative deaths, from postoperative myocardial infarction (n = 1) and pulmonary embolus (n = 1). There were 12 late deaths, from coronary artery disease (n = 4), cancer (n = 2), respiratory failure (n = 2), sepsis (n = 1), or unknown cause (n = 3). Median length of stay was 2 days (mean, 4 days). There have been no AAA ruptures after successful implantation of the device, no graft limb thromboses, and no limb dislocations. At the time of operation endoleak was noted in 43 (19%) patients, but by 6 months this was reduced to 8 (5.9%) patients (type I, n = 1; type II, n = 7). There were no type III or type IV endoleaks. Secondary interventions to treat endoleaks included open conversion (n = 2), placement of extension cuffs (n = 4), repeated balloon dilation (n = 3), and coil embolization (n = 6). The two remaining secondary interventions were emergent treatment of postoperative bleeding from a groin incision, and a colon resection because of postoperative colonic ischemia, for a 12-month secondary intervention rate of 7.5%. Wireform fractures were noted in the first generation Lifepath device in 37 of 79 (47%) patients. Graft migration (>10 mm) was observed in five patients (2.2%), each of whom also had two or more fractures of the proximal anchoring wireforms. Migration resulted in a proximal attachment endoleak in one patient. In response to wireform fractures, the device was modified after the initial 79 patients were enrolled. Wireform fracture has been observed in six patients since this modification (4%), and in only one patient did this involve fracture of a proximal anchoring wireform; none of these patients has had endoleak or graft migration. By 12 months, mean aneurysm diameter was noted to decrease by 9 mm (P < .0001), and mean aneurysm volume by 42 mL (P < .0001) from the preoperative visit.ConclusionThe Lifepath System demonstrates a low endoleak and secondary intervention rate and high sac regression rate, compared with other devices. The unique balloon-expandable design offers the advantages of precise placement and high radial force. The device appears to be highly resistant to limb thrombosis and modular component separation. Patients were protected from AAA rupture after successful device implantation, and demonstrated significant reduction in AAA diameter and volume. Fractures of the wireforms of the main body of the device have been observed. Careful long-term follow-up is necessary.

ObjectivesWe evaluated mid-term results of the multicenter EVT/Guidant aortouniiliac endograft (AI) trial and ascertained the durability of this endovascular technique in patients unable to undergo standard bifurcated endografting.MethodsFrom November 1996 to December 1998, 121 patients were enrolled to receive the AI device on the basis of complex iliac artery anatomy contraindicating bifurcated endografting. Clinical data were centrally collected, and radiographic data were evaluated by core facility.ResultsAI placement was technically successful in 113 of 121 patients. At operation, patients who underwent AI had significantly more arrhythmias, congestive heart failure, and peripheral occlusive disease (P < .05) compared with patients who underwent open aneurysmorrhaphy in the EVT/Guidant trials, indicating comorbid features in this anatomic cohort. Distal AI attachment was performed to the external iliac artery in 40 (36%) patients. Median follow-up was 38 months. In the AI group, overall aneurysm diameter decreased over the duration of study from 54.4 ± 9.6 mm to 44.4 ± 16.4 mm (P = .004). At 24 and 36 months after repair, reduction in aneurysm size was associated with absence of endoleak (P = .003 and P = .008, respectively). Aneurysms shrunk or remained stable in 109 (96.5%) patients. Endoleak was identified in 52.3% of patients at discharge, and at follow-up in 30.9% at 1 year, 34.8% at 2 years, 28.6% at 3 years, and 30.4% at 4 years. Type II endoleak predominated. Leak from failure to completely occlude contralateral iliac flow accounted for 8 of 58 endoleaks (13.8%) at discharge. Sixteen patients (14.2%) underwent postoperative endoleak treatment; in one of these patients open conversion was necessary at 20 months. Post-procedure thigh or buttock claudication developed in 16 patients (14.2%). Thirteen patients (81.3%) had either distal attachment in the external iliac artery or contralateral type IIA occlusion. Fifteen patients (13.3%) required intervention because of reduced limb flow; one of these patients underwent open conversion at 27 months, and another underwent axillofemoral grafting at 28 months. Device migration was confirmed in 2 (1.8%) patients, without current clinical sequelae. Whereas no femorofemoral graft thromboses occurred, graft infection developed in 3 patients (2.6%). During follow-up, aneurysm in 2 patients ruptured. Late death occurred in 41 patients (36.3%). Twenty-four patients (58.5%) died of cardiopulmonary disease; one death was endograft-related after aneurysm rupture; and one death was related to femorofemoral bypass infection. Actuarial survival was 78.4% (95% confidence interval [CI], 71%-86%) at 2 years and 63.4% (95% CI, 54%-73%) at 4 years.ConclusionsIn patients with significant comorbid conditions and complex iliac anatomy unfavorable for bifurcated endografting, AI with femorofemoral bypass grafting is safe and effective. In most patients this endovascular option provides satisfactory mid-term results.

Purpose: Unlike abdominal aortic aneurysm repair, little information exists regarding aortic-related morbidity (synchronous/metachronous aneurysm or graft-related complications) after thoracoabdominal aneurysm (TAA) repair. This study was performed to define such events and identify factors related to their development. Methods: Over a 15-year interval, 333 patients underwent TAA repair (type I, n = 90; 27%; type II, n = 59; 18%; type III, n = 118; 35%; and type IV, n = 66; 20%). Late aortic events were defined as aortic disease causing death or necessitating further intervention or graft-related complications (infection, pseudoaneurysm, branch occlusion) after hospital discharge. Variables were assessed for their association with aortic events with Cox proportional hazards regression. Results: In-hospital mortality occurred in 28 patients (8.4%), which left 305 available for follow-up (mean length of follow-up, 26 months; interquartile range, 2.7 to 38.4 months). After TAA repair, aneurysm remained in 60 patients (19.7%; ascending/arch, n = 41; 68.3%; discontinuous infrarenal, n = 12; 20%; contiguous descending, n = 7; 11.7%; contiguous abdominal, n = 4; 6.7%). Events occurred in 33 individuals (10.8%) at 30 ± 27 months after surgery. Twenty-four patients (73% of events; 7.9% of cohort) had aortic-related events, including another elective aneurysm repair (n = 16), urgent/emergent aneurysm operation (n = 5), acute dissection (n = 2), and atherothrombotic embolization (n = 1). Nine patients (27% of events; 2.9% of cohort) had graft-related incidents, including renovisceral occlusion (n = 5), visceral patch pseudoaneurysm (n = 2), graft infection (n = 2), and graft-esophageal fistula (n = 1). Variables independently predictive of events were female gender (odds ratio [OR], 2.3; P = .03), initial aneurysm rupture (OR, 4.8; P = .04), partial disease resection (OR, 4.2; P = .0008), and expansion of remaining aortic segments on imaging surveillance (OR, 2.5; P = .03). The event-free survival rates were 96% (95% CI, 93% to 98%) and 71% (95% CI, 60% to 83%) at 1 and 5 years. Conclusion: Late aortic events occur in at least 10% of patients after TAA repair and are usually the result of native aortic disease in remote (or noncontiguous) aortic segments. Graft-related complications, in particular, degeneration of inclusion anastamoses, are rare. Female gender, original presentation with rupture, and unresected disease identify those at highest risk. These findings verify the anatomic durability of TAA repair and suggest indefinite aortic surveillance is indicated for those at risk of events. (J Vasc Surg 2003;37:254-61.)

Purpose: Analysis endpoints of patient survival and aortic rupture at a reporting interval of 12 months are regularly used to compare endograft aortic aneurysm (EAG) repair to conventional open surgical (COS) repair. This study reports a multicenter EAG repair versus COS repair parallel cohort trial at 12 months and additional observations of specific device failure types and their impact on an aortic endograft design beyond that follow-up period. Methods: From August 1997 to September 1998, 240 patients who were treated with bifurcation EAG repairs and 28 patients who were treated with straight EAG repairs were compared with 98 patients who were treated with COS repair for elective infrarenal aortic aneurysm repair. Allocation to treatment was based on aneurysm anatomy. All cohorts underwent infrarenal procedures. Data from concurrent, nonrandomized patient accrual from 17 United States institutions were prospectively gathered and independently adjudicated for safety and efficacy. An independent core laboratory evaluated all imaging data. Results: There were 308 men and 58 women (mean age, 72 years; range, 42-94 years) treated for infrarenal aortic aneurysm (mean diameter, 55 mm; range, 40-115 mm). Mean preoperative aneurysm diameters were clinically similar (EAG repair, 54 mm vs COS repair, 57 mm). The two cohorts were not significantly different in terms of gender ( P = .30) or age ( P = .32). EAG repair technical success (aneurysm exclusion, graft patency, patient survival) at 30 days was 89.2%. Five patients required immediate conversion to COS repair, four caused by access complications and one caused by operator-induced EAG repair malposition. The 30-day mortality rate was 1.5% for EAG repair and 3.1% for COS repair ( P = .59). The 12-month survival rate was 94.3% for EAG repair and 95.9% for COS repair. The intermediate-term cumulative survival rate at 24 months was 84.9% for EAG repair and 80.3% for COS repair ( P = .48). EAG repair device failure occurred from fabric erosion in six patients, with two deaths from ruptured aneurysm at 18 and 28 months after endografting and four device failures resolved by secondary procedures. Five endograft limb dislocations were all resolved by secondary endovascular procedures. Major or minor endograft migration required secondary procedures in five patients, including conversion in two patients. Conclusion: The clinical outcome at 12 months demonstrated effective aneurysm treatment and comparable safety between EAG repair and COS repair by conventional endpoints. Ongoing follow-up beyond 12 months revealed device-related adverse events that required endograft design changes. Diligent surveillance of outcomes beyond 12 months is necessary to adequately evaluate EAG repair devices. (J Vasc Surg 2001;33:S55-63.)

Purpose: We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. Methods: From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 ± 3°C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T9 to L1 region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. Results: The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35.3; 95% CI, 5.3 to 233; P

Objective: The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease. Methods: We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils. Results : The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients. Conclusions: These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy. (J Vasc Surg 2000;31:1135-41.)

Purpose: We reviewed a 13-year experience with an emphasis on long-term survival and renal function response when renal artery reconstruction (RAR) was performed primarily for the preservation or restoration of renal function in patients who had atherosclerotic renovascular disease.Methods: From January 1, 1980, to June 30, 1993, 139 patients underwent RAR for renal function salvage and were retrospectively reviewed. Inclusion criteria were either preoperative serum creatinine level >2.0 mg/dl (67% of patients) or RAR to the entire functioning renal mass irrespective of baseline renal function. Patient survival was calculated by life-table methods. Cox regression analysis was used to determine relative risk (RR) estimates for the late outcomes of continued deterioration of renal function and late survival after RAR. A logistic regression model was used to evaluate variables associated with perioperative complications.Results: Clinical characteristics of the cohort were notable for advanced cardiac (history of congestive heart failure, 27%; angina, 22%; previous myocardial infarction, 19%) and renal disease (serum creatinine level 3.0 mg/dl, 27%). Cardiac disease was the principle cause of early (6 of 11 operative deaths) and late death. Operative management consisted of aortorenal bypass in 47%, extraanatomic bypass in 45%, and endarterectomy in 8%; 45% of patients required combined aortic and RAR. The operative mortality rate was 8%; significant perioperative renal dysfunction occurred in 10%. Major operative morbidity was associated with increasing azotemia (RR = 2.1; p = 0.001; 95% confidence interval [CI], 1.3 to 4.7 for each 1.0 mg/dl increase in baseline creatinine level). Of those patients who had a baseline creatinine level ≥2.0 mg/dl, 54% had ≥20% reduction in creatinine level after RAR. Late follow-up data were available for 87% of operative survivors at a mean duration of 4 years (range, 6 weeks to 12.6 years). Actuarial survival at 5 years was 52% ± 5%. Continued deterioration in renal function occurred in 24% of patients who survived operation, and eventual dialysis was required in 15%. Deterioration of renal function after RAR was associated with increasing levels of preoperative creatinine (RR = 1.6; 95% CI, 1.2 to 1.8; p = 0.001 for each 1.0 mg/dl increment in baseline creatinine level), and inversely related to early postoperative improvement in creatinine level (RR = 0.41; 95% CI, 0.2 to 0.9; p = 0.04).Conclusions: Intervention before major deterioration in renal function and an aggressive posture toward the frequently associated coronary artery disease are necessary to improve long-term results when RAR is performed for renal function salvage. (J Vasc Surg 1996;24:371-82.)

Objectives:To evaluate a number of currently available methods for intraoperative assessment of infrainguinal bypass grafts (IBG) in terms of detecting technical errors and predicting graft failure.Design:Prospective open clinical study.Methods:Forty-nine patients undergoing 54 consecutive IBG were studied. Intraoperatively, the following measurements were performed: distal pulse palpation (DPP), continuous wave Doppler (CWD), pulse volume recording (PVR), and ultrasonic volume flowmetry (UVF), followed by intraoperative angiography of the entire graft and runoff vessels. The outflow resistance was graded according to the guidelines of the Society for Vascular Surgery and International Society for Cardiovascular Surgery (SVS/ISCVS runoff score). Graft patency was determined noninvasively (PVR, colour Duplex) up to 12 months following surgery. Predictive values and likelihood ratios for the intraoperative tests in detecting a technical problem during the bypass procedure and in predicting early graft failure were calculated.Results:There were five immediate revisions for problems detected intraoperatively. Angiography did not identify any additional problems but assisted in the correct location of the problems detected by the other tests. DPP and CWD were highly significant indicators of the need for revision with likelihood ratios for a positive test of 14.7 (p < 0.01) and 12.3 (p < 0.01) respectively. PVR did not achieve statistical significance in this respect. None of the intraoperative tests was a statistically significant predictor of early graft failure. The SVS/ISCVS runoff score, on the other hand, predicted early failure with a PPV of 33% (likelihood ratio for a positive test of 4.9, p < 0.05). None of the grafts with a perfect SVS/ISCVS runoff score (n = 39) failed in the first postoperative month.Conclusions:Simple CWD insonation of graft and anastomoses is the best intraoperative indicator for technical inadequacies after IBG. Routine intraoperative angiography is not necessary and intraoperative anatomical imaging may be reserved for situations in which noninvasive documentation of technical success is absent. Contrary to the intraoperative haemodynamic test results, the SVS/ISCVS runoff score is a good predictor of early graft failure.

Purpose: In a retrospective study the outcome of 70 carotid endarterectomies (CEA) in 68 patients with neurologically unstable conditions or anatomically compelling findings on carotid angiography was examined to more accurately identify patients who might benefit from CEA in this setting. Methods: Out of a total of 1734 CEAs performed from 1978 to 1992, five groups of patients were selected: group A, stroke in evolution with tight stenosis ( n = 5); group C, crescendo transient ischemic attacks (CTIA) continuing despite heparin ( n = 14); group D, CTIA (above criteria) ceasing with heparin ( n = 21); and group E, anatomically compelling situation on carotid angiography ( n = 13). Data collected included preoperative and postoperative Neurologic Event Severity Score (NESS), CHAT classification, arteriosclerosis risk factors, demographics, and long-term overall and transient ischemic attack/stroke-free survival rates. Results: Risk factors and demographics were similar in all groups. By NESS criteria the conditions of 97.3% of patients in the neurologically unstable groups A to C were improved or stabilized after operation, with one deterioration (2.7%). All patients in group B either stabilized or improved. In group D, one patient's NESS deteriorated, resulting in 3.5% overall morbidity rate and no deaths for groups A to D. Follow-up showed an overall survival rate by Kaplan-Meier analysis equivalent to a matched control population, with 85% alive at 5 years. The cumulative TIA/stroke-free survival rate at 5 years was 75%. Conclusions: In this retrospective series, CEA performed for compelling or unstable neurologic findings carried low morbidity and mortality rates. Early aggressive surgical therapy of neurologically unstable patients may be warranted because our results improved on the anticipated natural history of the conditions studied. Further clarification of proper patient selection is necessary before this principle can be applied broadly. (J VASC SURG 1994;19:32-42.)

OBJECTIVE--To determine if the oil spillage from the tanker Braer had any immediate health effects on the exposed resident population. DESIGN--Cohort study with a comparison against controls, exposure status being assigned on the basis of geographical location. SETTING--Rural Shetland. SUBJECTS--All those resident on or after 5 January 1993 (day 0) within 4.5 km of the site of tanker's grounding. Controls matched for sex and age were drawn from a general practice list 95 km distant. OUTCOME MEASURES--Demographic details; smoking and alcohol consumption; perception of health and reported presence or absence of specific symptoms; peak expiratory flow; results of haematology, liver and renal function tests, and blood and urine toxicology. RESULTS--Of subjects contacted, 420 (66%) exposed people and 92 (68%) controls were studied; 56 non-attenders were surveyed. Principal health effects arose on days 1 and 2 and were headache, throat irritation, and itchy eyes. No significant differences between those exposed and controls were found for any of the biological markers. Toxicological studies did not show any exposures that are known to affect human health. CONCLUSIONS--The study confirmed the anecdotal reports of certain acute symptoms. No evidence of pulmonary, haematological, renal, or hepatic damage was detected at the population level. Toxicological samples from exposed people did not find levels known to affect human health. Further studies are required to ascertain whether there have been any long term effects on the population.

Carotid body tumors may occur sporadically (90%) or in a familial pattern (10%). One third of the patients with familial disease have bilateral tumors. We report the case of a patient with bilateral carotid body tumors and a strong family history of such tumors. Details of his evaluation and treatment are reviewed. Relatives of patients with carotid body tumors should be examined carefully, and any suspicious neck mass should be appropriately investigated.

BACKGROUND: International studies have shown that cancer survival was generally low in the UK and the Republic of Ireland compared to western and northern European countries, but no systematic comparative analysis has been performed between the UK countries and the Republic of Ireland. METHODS: Population-based survival for 20 adult malignancies was estimated for the UK and the Republic of Ireland. Data on adults (15-99 years) diagnosed between 1991 and 1999 in England, Scotland, Wales, Northern Ireland (1993-99) and the Republic of Ireland (1994-99) were analysed. All cases were followed up until the end of 2001. Relative survival was estimated by sex, period of diagnosis and country, and for the nine regions of England. Predicted survival was estimated using the hybrid approach. RESULTS: Overall, cancer survival in UK and Republic of Ireland improved during the 1990s, but there was geographic variation in survival across the UK and Republic of Ireland. Survival was generally highest in Ireland and Northern Ireland and lowest in England and Wales. Survival tended to be higher in Scotland for cancers for which early detection methods were in place. In England, survival tended to be lower in the north and higher in the south. CONCLUSIONS: The geographic variations in survival seen across the UK and Republic of Ireland are narrower than between these countries and comparable European countries. Artefact is likely to explain some, but not all of the differences across the UK and Republic of Ireland. Geographic differences in stage at diagnosis, co-morbidity and other clinical factors may also be relevant.

To determine if recent trends in evaluation and therapy have contributed to the successful surgical management of carotid body paragangliomas, we reviewed our experience over the past decade. Nineteen carotid body paragangliomas were identified in 17 patients. Eleven patients underwent complete, preoperative embolization of their afferent arteries with one complication. Calculated carotid body paragangliomas surface areas did not differ between the embolized 64.6 ± 43.3 cm 2 and nonembolized 63.0 ± 57.9 cm 2 lesions. Intraoperative blood loss was lower ( p = 0.02) in the patients treated with embolization (372 ± 213 ml) compared with their cohorts (609 ± 564 ml). However, the operative times were equivalent 4.1 hours versus 4.5 hours in both groups. Intraoperative electroencephalographic (EEG) monitoring was used in 10 patients; in one patient the EEG indicated intraoperative thrombosis of the carotid artery, which was successfully treated by thrombectomy without complications. Two patients required carotid bifurcation resection and vascular reconstruction to remove the entire tumor; a late stroke manifested by contralateral hand weakness developed in one of these patients. The incidence of cranial nerve injury was low at 16%, with one transient ramus mandibularis paresis and two instances of vocal cord dysfunction. Two additional patients had a postoperative Horner's syndrome. We conclude that by diminishing intraoperative blood loss through complete and careful preoperative embolization and use of intraoperative EEG monitoring along with careful surgical technique, the complications associated with this challenging operation are facilitated and diminished. (J Vasc Surg 1992;15: 1035–45.)

Background:Identifying and addressing the requirements of cancer survivors is currently a high priority for the NHS, yet little is known about the population of cancer survivors in the United Kingdom.Methods:Data from cancer registries in England, Northern Ireland, Scotland and Wales were analysed to provide limited-duration prevalence estimates for 2004. Log-linear regression models were used to extend these to complete prevalence estimates. Trends in prevalence from 2000 to 2004 were used to project complete prevalence estimates forward from 2004 to 2008.Results:We estimated that in total, there were 2 million cancer survivors in the United Kingdom at the end of 2008, ∼3% of the population overall and 1 in 8 of those aged 65 years and more. Prostate and female breast cancers were the most prevalent. The number of cancer survivors is increasing by ∼3% each year. Estimates are also provided by time since diagnosis.Conclusion:These estimates are the most up-to-date available, and as such will be useful for statutory and voluntary sector organisations that are responsible for planning and providing treatment and support to cancer survivors in the United Kingdom.

ObjectiveWe performed a device-specific comparison of long-term outcomes following endovascular abdominal aortic aneurysm repair (EVAR) to determine the effect(s) of device type on early and late clinical outcomes. In addition, the impact of performing EVAR both within and outside of specific instructions for use (IFU) for each device was examined.MethodsBetween January 8, 1999 and December 31, 2005, 565 patients underwent EVAR utilizing one of three commercially available stent graft devices. Study outcomes included perioperative (≤30 days) mortality, intraoperative technical complications and need for adjunctive procedures, aneurysm rupture, aneurysm-related mortality, conversion to open repair, reintervention, development and/or resolution of endoleak, device related adverse events (migration, thrombosis, or kinking), and a combined endpoint of any graft-related adverse event (GRAE). Study outcomes were correlated by aneurysm morphology that was within or outside of the recommended device IFU. χ2 and Kaplan Meier methods were used for analysis.ResultsGrafts implanted included 177 Cook Zenith (CZ, 31%), 111 Gore Excluder (GE, 20%), and 277 Medtronic AneuRx (MA, 49%); 39.3% of grafts were placed outside of at least one IFU parameter. Mean follow-up was 30 ± 21 months and was shorter for CZ (20 months CZ vs 35 and 31 months for GE and MA, respectively; P < .001). Overall actuarial 5-year freedom from aneurysm-related death, reintervention, and GRAE was similar among devices. CZ had a lower number of graft migration events (0 CZ vs 1 GE and 9 MA); however, there was no difference between devices on actuarial analysis. Combined GRAE was lowest for CZ (29% CZ, 35% GE, and 43% MA; P = .01). Graft placement outside of IFU was associated with similar 5-year freedom from aneurysm-related death, migration, and reintervention (P > .05), but a lower freedom from GRAE (74% outside IFU vs 86% within IFU; P = .021), likely related to a higher incidence of graft thrombosis (2.3% outside IFU vs 0.3% within IFU; P = .026). The differences in outcome for grafts placed within vs outside IFU were not device-specific.ConclusionEVAR performed with three commercially available devices provided similar clinically relevant outcomes at 5 years, although no graft migration occurred with a suprarenal fixation device. As anticipated, application outside of anatomically specific IFU variables had an incremental negative effect on late results, indicating that adherence to such IFU guidelines is appropriate clinical practice.

Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI.During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence.Baseline comorbidities, with the exception of heart disease (P=.025) and serum albumin3.5 g/dL (P=.025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P=.001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P=.001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P=.23) or mortality (1/31 vs 1/49, P=.74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P=.28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P=.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P=.40) between the two groups. Radiographic primary patency (58% vs 90%, P=.001) and primary assisted patency (65% vs 96%, P.001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P=.49).Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations.

Objective: The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 12-year experience with EVAR to document late outcomes. Methods: During the interval January 7, 1994 through December 31, 2005, 873 patients underwent EVAR utilizing 10 different stent graft devices. Primary outcomes examined included operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency was also determined. Finally, the need for reintervention and success of such secondary procedures were evaluated. Kaplan-Meier and multivariate methodology were used for analysis. Results: Mean patient age was 75.7 years (range, 49-99 years); 81.4% were male. Mean follow-up was 27 months; 39.3% of patients had 2 or more major comorbidities, and 19.5% would be categorized as unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. Thirty-day mortality was 1.8%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.6% at 5 years and 94% at 9 years. Significant risk factors for late AAA rupture included female gender (odds ratio OR, 6.9; P = 0.004) and device-related endoleak (OR, 16.06; P = 0.009). Aneurysm-related death was avoided in 96.1% of patients, with the need for any reintervention (OR, 5.7 P = 0.006), family history of aneurysmal disease (OR, 9.5; P = 0.075), and renal insufficiency (OR, 7.1; P = 0.003) among its most important predictors. 87(10%) patients required reintervention, with 92% of such procedures being catheter-based and a success rate of 84%. Significant predictors of reintervention included use of first-generation devices (OR, 1.2; P < 0.01) and late onset endoleak (OR, 64; P < 0.001). Current generation stent grafts correlated with significantly improved outcomes. Cumulative freedom from conversion to open repair was 93.3% at 5 through 9 years, with the need for prior reintervention (OR, 16.7; P = 0.001) its most important predictor. Cumulative survival was 52% at 5 years. Conclusions: EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.

Objective Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta. Methods A review of patients undergoing SG procedures and open surgery of the thoracic aorta from January 1, 1996, to November 30, 2005, was performed from a prospectively compiled database. Study end points included perioperative complications, late survival, freedom from reinterventions, and graft-related complications. Multivariate methods were used to assess variables potentially associated with study end points; late outcomes were compared with actuarial methods. Results In 105 patients (mean age, 70 years; 66 male [62.9%]) SG repairs were done for 68 degenerative aneurysms (64.7%), 12 penetrating ulcers (11.4%), 15 pseudoaneurysms (14.3%), 9 traumatic tears (8.6%), and 1 acute dissection (0.9%). Mean follow-up was 22 months (range, 0 to 101 months). Eighty-nine (84.8%) SG patients were asymptomatic at presentation and underwent elective repair, whereas 16 (15.2%) presented with acute conditions and underwent urgent repair. Perioperative mortality was 7.6% (8/105), and actuarial survival at 48 months was 54% ± 7%. The perioperative mortality rate among SG patients treated for degenerative pathology was 10.4% (8/77). Seven (6.7%) of 105 patients experienced spinal cord ischemic complications, including 2 patients with transient paraparesis that resolved by the time of discharge. Reinterventions were performed in 10.5% of patients (11/105), with freedom from reintervention approaching 81% by 48 months. Over the same interval, 93 patients were treated with open-surgical repair for descending thoracic aneurysm (anastomosis cephalad to the celiac axis). Perioperative mortality in the open cohort was 15.1% (14/93; P = .09 vs SG repair), and the 48-month actuarial survival was 64% ± 6%. The incidence of spinal cord ischemic complications was 8.6% (8/93), including 4 patients with transient paraparesis ( P = .44 vs SG repair). Nine patients (9.7%) required surgical reintervention during the follow-up period, with 48-month freedom from reintervention approaching 79% ( P = .73 vs SG repair). Conclusions Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications.

A truncated left-censored and right-censored lognormal model has been validated for representing pleural mesothelioma survival times in the range 5-200 weeks for data subsets grouped by age for males, 40-49, 50-59, 60-69, 70-79 and 80+ years and for all ages combined for females. The cases available for study were from Europe and USA and totalled 5580. This is larger than any other pleural mesothelioma cohort accrued for study. The methodology describes the computation of reference baseline probabilities, 5-200 weeks, which can be used in clinical trials to assess results of future promising treatment methods. This study is an extension of previous lognormal modelling by Mould et al (2002 Phys. Med. Biol. 47 3893-924) to predict long-term cancer survival from short-term data where the proportion cured is denoted by C and the uncured proportion, which can be represented by a lognormal, by (1 - C). Pleural mesothelioma is a special case when C = 0.

To determine the association of patent sac branch vessels (lumbar and inferior mesenteric arteries [IMAs]) with early endoleak rate after stent-graft repair of abdominal aortic aneurysm (AAA).Pre- and postoperative computed tomographic (CT) angiograms in 158 patients who underwent stent-graft AAA repair were retrospectively reviewed to determine the preoperative patency of IMAs and other sac branch vessels (feeders) and presence or absence of immediate postoperative endoleak. Relationships of early endoleak rate with total branch vessel, IMA, and lumbar artery patency and graft type were evaluated.There was a significant association between patency of sac feeders and rate of early endoleak, especially type 2. As total patent feeders increased from zero to three to four to six, total endoleak rate increased from 6% (one of 17) to 35% (30 of 86); type 2 endoleak rate, from 0% to 25%. IMA patency was significantly associated with total early endoleak rate. Increasing lumbar artery patency also was associated with significantly higher total and type 2 endoleak rates: With zero to three lumbar arteries, the total endoleak rate was 17% and type 2 endoleak rate was 13%, as compared with 60% and 50%, respectively, with more than six patent lumbar arteries.Sac branch vessel patency is associated with significantly higher early total and type 2 endoleak rates after stent-graft repair of AAAs; thus, patent sac branches play an important role in the pathogenesis of endoleaks.

Objective:To study the factors leading to wound problems in patients with chronic renal insufficiency (CRI) with emphasis on subcutaneous vs. deep placement of grafts.Methods:The outcomes of patients undergoing an infrainguinal bypass with preoperative CRI (serum creatinine ≥ 2.0 mg/dl) were reviewed. Surgical site infection (SSI) was classified as superficial or deep according to the Centres for Disease Control standards.Results:Forty-two patients underwent a total of 47 infrainguinal bypasses for ischaemic rest pain or tissue loss. The graft location was partially or predominantly subcutaneous in 21 limbs (Group I) and 26 grafts were positioned in the anatomic or subfascial planes (Group II). In Group I, seven early (< 30 days postoperative), one intermediate (4–6 weeks postoperative), and one late (> 6 weeks postoperative) SSI's were found (9/21, 43%). In three of these patients the graft was exposed and two required removal. In contrast, only two early and one intermediate SSI's (3/26, 12%) were noted in Group II (p = 0.02). A logistic regression analysis, with twelve possible covariables to wound healing, confirmed the subcutaneous location to be the only controllable factor significantly predicting SSI (relative risk = 11.6, p = 0.01).Conclusions:The infrainguinal bypass in patients with CRI is associated with a high incidence of wound complications. In our retrospective series, the presence of a vascular conduit in the subcutaneous plane was connected with a higher rate of SSI. Despite the growing trend toward the use of the in situ bypass, CRI may represent a circumstance where deeply placed grafts should be used preferentially.

Although aortic aneurysm (AA) is primarily a disease of older age groups, younger (51 years) patients infrequently are admitted requiring AA surgery. We sought to compare the characteristics of these patients with those of a randomly selected group of older patients with AA.We identified 26 patients with AA (group I) under age 51 (mean age 44.8) treated surgically between 1977 and 1993, after excluding patients with acute aortic dissection, traumatic pseudoaneurysms, and ascending or arch aneurysms, and compared them with 75 randomly selected patients with AA between the ages of 65 and 75 (mean age 70.3) who were surgically treated during the same time period (group II).Prevalence of hypertension, diabetes, coexisting heart, kidney, or occlusive peripheral vascular disease was similar between the two groups, and familial aneurysm rates and sex distribution did not differ significantly. More patients in group I had symptoms at the time of presentation (46% vs 6.7%, p0.001), and they also had larger AAs (6.9 cm vs 6.0 cm, p = 0.01). Definable causes of aneurysmal disease, such as Takayasu's, Cogan's, and Marfan syndromes, were more common among the young patients (23% vs 0%, p = 0.01), but most (77%) young patients did not have an identifiable syndrome associated with their aneurysm disease. Group I had a marked shift toward proximal aneurysms, defined as involvement of juxtarenal, suprarenal, or thoracoabdominal aorta (46% vs 18% in group II, p0.01). This difference persisted even when aneurysms associated with the above syndromes were excluded from consideration (p = 0.02). Cigarette smoking was much more common among the young patients (83% vs 51% in group II, p0.01). Smoking in group II was associated with more extensive aneurysm disease (p = 0.04).Aneurysmal disease presenting in the young adult is more likely to be symptomatic and associated with more proximal aortic involvement than aneurysmal disease in older patients. Smoking appears to play an important role in the pathogenesis of aneurysmal disease in the young patient and was associated in our study with more proximal aneurysms among older patients. A subgroup of patients at risk for early and aggressive aneurysm disease is suggested by these data.

Among various surgical techniques for renal artery reconstruction (RAR), anatomic aortorenal bypass has been the preferred standard. Yet concern regarding origin of the bypass from a diseased aorta and desire to avoid a major aortic operation in these patients who are often at poor risk has led to increasing use of extraanatomic bypass grafting, particularly hepatorenal and splenorenal bypass. This study was conducted to compare the safety and long-term performance of these different techniques of renal artery reconstruction.We reviewed a 15-year (1976 to 1991) experience with 323 surgical RAR performed in 285 patients with atherosclerotic renovascular disease. Long-term patency and survival rates were analyzed by life-table methods. Variables potentially affecting early failure of the RAR and perioperative and late mortality rates were examined by Cox proportional hazards models.Diffuse atherosclerosis characterized the patients' clinical profile. Clinically evident coronary artery disease was present in 54% of patients, and some degree of renal insufficiency was present in 60%. Ninety-five percent of patients had hypertension with poor control of hypertension seen in 50%. Aortic disease necessitated combined aortic grafting and RAR in 43% of the study group. Various techniques of RAR were used as follows: endarterectomy or patch angioplasty, 8.5%; extraanatomic bypass grafting, 37% (hepatorenal, 62; splenorenal, 52; iliorenal, 7); and aortorenal bypass grafting, 54% (native aorta, 34; combined aortic graft and RAR, 140). Early failure of the RAR occurred in 5% of cases, and the operative mortality rate for the entire cohort was 5.6%. Median follow-up duration was 9.4 years. A comparison of early and late patency for the major types of RAR revealed equivalent (p = 0.44) performance of aortorenal and extraanatomic bypass grafting. Perioperative complications occurred more frequently (p0.02) in patients undergoing combined operations. The cumulative 5-year survival rate for all patients was 75%.Because extraanatomic bypass grafting can provide long-term results equivalent to aortorenal bypass grafting, the choice among techniques for RAR in patients with diffuse atherosclerosis should be based on both technical and operative safety considerations, rather than adherence to aortorenal bypass grafting as an inherently superior technique.

In the course of reviewing a 10-year experience with popliteal artery embolism (PAE), two distinct patterns of clinical presentation were identified. In addition to those patients presenting with typical acute (symptom duration less than 7 days) arterial ischemia, a second group was identified who presented with more chronic symptoms. The present study was conducted to contrast the clinical factors and treatment of these two temporal patterns of presentation with PAE. Sixty PAEs in 58 patients were documented by the combination of angiography and/or exploration of the popliteal artery. Acute presentation (AP) was seen in 41 (68%) of these and delayed presentation (DP) was noted in 19 (32%) patients. Delayed presentation patients typically presented with a history of sudden onset of claudication or rest pain and a median symptom duration of 30 days. Eighty per cent of AP patients presented with immediately threatened limbs. Angiography was generally diagnostic of chronic popliteal embolism. In the acute group, 90% were treated with embolectomy alone, while 20% of the DP group required bypass grafting. However in two thirds of the DP group, embolectomy alone performed through a direct popliteal approach was possible. Current results with overall limb salvage (92%) and mortality (7%) represents a substantial improvement compared to the authors' previous experience with PAE. The current study suggests that as many as one third of patients with popliteal artery embolism may present in delayed fashion with chronic symptoms. Furthermore most of these patients can be treated with direct popliteal embolectomy alone with favorable results.

One of the major factors in the progress of vascular surgery involving the abdominal aorta in the past two decades has been the advancement of angiography [I]. Such studies have proved increasingly safe and informative, revealing significant information about the aortic lesion as well as associated vascular abnormalities, and we as well as some other vascular surgeons now routinely employ preoperative angiography in the elective evaluation of arteriosclerotic abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease [2]. One of the principal findings, and a major reason for the use of preoperative angiography, has been the high incidence of renal artery abnormalities coexistent with arteriosclerotic disease of the distal abdominal aorta. However, when arteriosclerotic stenoses or other lesions of the renal arteries are found in patients requiring aortic reconstruction for either aneurysmal or occlusive disease, the surgeon must decide if simultaneous correction of both lesions should be undertaken. To clarify indications for such decisions, the experience at the Massachusetts General Hospital with combined operations involving both aortic reconstruction and renal revascularization has been reviewed and evaluated.

Selective laser ablation of human atherosclerotic plaque is possible because endogenous carotenoid pigments found in atherosclerotic plaque confer a twofold preferential absorption of laser radiation at 450 to 500 nm. In this study, patients with carotid endarterectomy were pretreated with oral beta carotene to determine if the carotenoid content and therefore laser selectivity of plaque could be increased in vivo. Beta carotene-treated patients had a significant, nearly twofold increase in their plaque carotenoid concentration, which increased from 0.22 to 0.40 μg beta carotene/mg cholesterol. These results suggest that selective ablation of atherosclerotic plaque may be enhanced by pretreating patients with doses of oral beta carotene for short periods of time. (J Vasc Surg 1989;9:563–7.)

The initial outcome, long-term patency rate, and rate of limb salvage were studied in patients after regional urokinase infusion for treatment of thrombosed lower-extremity grafts. Seventy-one infusions were performed in 53 patients. Complete clot lysis occurred in 75% of grafts, with establishment of antegrade blood flow in 66%. Variables that favorably influenced clot lysis and the reestablishment of antegrade blood flow through the graft were a short duration of occlusion and a suprainguinal graft position. The median duration of patency after infusion and adjunctive therapy was 162 days, with 75% limb salvage at 301 days. No statistically significant variables that influenced the length of patency were identified. These long-term patency results are inferior to the reported results in suprainguinal grafts after reoperation. They appear similar to reported results for occluded infrainguinal grafts treated with thrombectomy and patch grafting.

The use of transcutaneous oxygen tension (TCpO2) measurements to objectively and noninvasively diagnose peripheral arterial occlusive disease (PAOD) and to aid in the planning of vascular surgery was investigated. Thirty-two normal subjects and 100 patients with PAOD were studied. TCpO2 values decreased with age; when normalized by measurements on the chest, they did not. Absolute and normalized values of TCpO2 were equally effective in identifying the presence of PAOD and accurately characterized different degrees of severity (claudication vs. rest pain vs. impending gangrene; p less than 0.001). This was true even in diabetic patients, in whom tests based on hemodynamic function were less reliable. Healing of amputations was observed when TCpO2 greater than or equal to 38 mm Hg either preoperatively or after reconstruction; failure to heal in the absence of infection was associated with TCpO2 less than or equal to 38 mm Hg. The need for revascularization was associated with TCpO2 less than 30 mm Hg. A similar distribution of TCpO2 values was associated with success vs. failure of ulcer healing. TCpO2 is a useful complement to standard hemodynamic tests in the diagnosis and management of PAOD and, in addition, provides some distinct advantages.

Chondroma of the trachea is an extremely rare neoplasm. A patient is described who required surgical treatment for this abnormality on three separate occasions over a nineteen-year period. The last two instances represent either local recurrence or new primary growths. The most recent presentation was that of a very large mediastinal mass causing tracheal compression, dysphagia, and superior vena caval obstruction. The clinical and pathological features of chondromas of the tracheobronchial tree are discussed. Because of its recognized potential for local recurrence, a localized chondroma of the trachea is best managed by tracheal resection.

A prospective, preoperative study was conducted of 50 electively repaired abdominal aortic aneurysms comparing the CT and angiographic findings with those described at surgery. CT demonstrated all 50 aneurysms and correctly identified their proximal extent in relation to the takeoff of the renal arteries in 47 patients (94%), while angiography detected 48 aneurysms (96%) and their correct relation to the renal arteries in all (100%). CT correctly identified 40 (98%) of 41 patients with two renal arteries, but only two (29%) of seven with three and none of two patients with four arteries. Common iliac artery involvement or lack thereof was accurately predicted in 42 (84%) of the 50 patients and internal iliac artery aneurysms found in one (33%) of three patients. It was concluded that CT is not sufficiently accurate for documenting location and patency of the renal arteries to allow its routine substitution for angiography in patients undergoing preoperative assessment of abdominal aortic aneurysms.

To assess the safety of percutaneous puncture for the angiographic study of aortofemoral bypass grafts, we reviewed the medical records of 58 patients who underwent a total of 86 graft punctures. Short-and long-term follow-up revealed that in 83 punctures there were no complications. In three instances (3.5%) there was acute thrombosis of the punctured limb of the graft. This complication may have expedited but did not substantially alter the surgical plans of managing the underlying clinical problem. Although the incidence of complications of direct graft puncture is higher than that associated with puncture of native vessels, alternative approaches are also associated with complications, many of which may be more serious. Therefore, for angiographic studies of patients with aortofemoral bypass grafts, we favor the direct percutaneous puncture provided that enough time has elapsed from surgery. (J VASC SURG 1984;1:642-5.)

To determine optimal methods of reoperation, experience with 157 secondary procedures for unilateral aortofemoral graft limb occlusion in 110 patients during a 16-year period was reviewed. In earlier years, inflow was reestablished by direct replacement of the graft limb or entire graft (11%); more recently, graft limb thrombectomy has been used most frequently (68%) with equal success, durability, and less morbidity. Femorofemoral grafts from the patent contralateral graft limb were employed in 18% of patients, usually those in whom thrombectomy was not attempted. Thrombolytic therapy (3%) appears to offer little advantage, is time-consuming, and occasionally causes significant complications. In addition to reestablishment of inflow, most patients also required revision of the femoral anastomosis to improve profunda femoris runoff; this was usually best accomplished by short segmental extension of the graft limb to the more distal deep femoral artery. Concomitant femoropopliteal bypass was done in 32% of patients and is indicated when preoperative angiography or specific intraoperative findings suggest inadequate profunda femoris outflow. An aggressive approach to reoperation appeared justified by long-term results (mean follow-up 37 months). Despite the need for repetitive reoperation in 26% of patients (two to five reoperations), graft limb patency was ultimately maintained in 78% and limb salvage achieved in 67% of patients, with an operative mortality rate of only 1.9%. (J VASC SURG 1987;5:363-74.)

Chronic aorto-iliac disease is manifested by progressive claudication, ischemic pain, ulceration, or gangrene. In properly selected patients good results have been obtained with aorto-iliac reconstruction by endarterectomy or bypass grafting with Dacron prostheses.

Objective: The purpose of this study was to present the experience with aneurysm rupture after deployment of Guidant/EVT (Guidant) endografts and review previously reported cases with other devices. Methods: Records from Guidant/EVT clinical trials and postmarket approval databases from February 1993 to August 2000 were analyzed to identify patients with rupture and to extract pertinent data. Previously reported cases were obtained with a Medline search. Results: Seven ruptures were found with Guidant/EVT devices. Five of these occurred among the 686 patients in US Food and Drug Administration protocols (group I) who were followed for a mean of 41.8 ± 21.9 months and limited to the subgroup of 93 first generation tube endografts. Two ruptures occurred in group II (3260 patients after market approval with limited follow-up), specifically in the subgroup of 166 patients who underwent treatment with second generation tube grafts. No ruptures were found in patients with bifurcation or unilateral iliac implants followed for a mean of 37.5 months. All ruptures were caused by distal aortic type I endoleaks on the basis of attachment system fractures (first generation devices only), aortic neck dilatations, persistent primary endoleaks, migration, overlooked imaging abnormalities, refused reintervention, and poor patient selection. The mortality rate was 57% (4/7) overall and was 50% for surgical repair (3/6). A literature search identified 40 additional ruptures related to other devices, for a total of 47. All 44 that were documented with adequate data were caused by endoleaks (26 type I, 2 type II, 11 type III, and 5 source not reported). Other contributing factors were graft module separation and graft wall deterioration. The overall mortality rate for the combined series was 50%, with an operative mortality rate of 41%. Conclusion: Postendograft AAA rupture is infrequent, although the true incidence rate is unclear because of inadequate follow-up of individual device designs. Tube endografts should be limited to the rare patient with ideal anatomy, no other alternatives, and at high risk for standard open repair. Prevention of aneurysm rupture requires long-term surveillance with attention to subtle imaging abnormalities and the establishment of reliable follow-up protocols for specific devices. The outcome of postendograft aneurysm rupture is similar to that of rupture without prior endograft therapy. (J Vasc Surg 2002;35:1155-62.)

Purpose: This report summarizes our experience with epidural cooling (EC) to achieve regional spinal cord hypothermia and thereby decrease the risk of spinal cord ischemic injury during the course of descending thoracic aneurysm (TA) and thoracoabdominal aneurysm (TAA) repair.Methods: During the interval July 1993 to Dec. 1995, 70 patients underwent TA (n = 9, 13%) or TAA (n = 61) (type I, 24 [34%], type II, 11 [15%], type III, 26 [37%]) repair using the EC technique. The latter was accomplished by continuous infusion of normal saline (4° C) into a T11-12 epidural catheter; an intrathecal catheter was placed at the L3-4 level for monitoring of cerebrospinal fluid temperature (CSFT) and pressure (CSFP). All operations (one exception, atriofemoral bypass) were performed with the clamp-and-sew technique, and 50% of patients had preservation of intercostal vessels at proximal or distal anastomoses (30%) or by separate inclusion button (20%). Neurologic outcome was compared with a published predictive model for the incidence of neurologic deficits after TAA repair and with a matched (Type IV excluded) consecutive, control group (n = 55) who underwent TAA repair in the period 1990 to 1993 before use of EC.Results: EC was successful in all patients, with a 1442 ± 718 ml mean (range, 200 to 3500 ml) volume of infusate; CSFT was reduced to a mean of 24° ± 3° C during aortic cross-clamping with maintenance of core temperature of 34° ± 0.8± C. Mean CSFP increased from baseline values of 13 ± 8 mm Hg to 31 ± 6 mm Hg during cross-clamp. Seven patients (10%) died within 60 days of surgery, but all survived long enough for evaluation of neurologic deficits. The EC group and control group were well-matched with respect to mean age, incidence of acute presentations/aortic dissection/aneurysm rupture, TAA type distribution, and aortic cross-clamp times. Two lower extremity neurologic deficits (2.9%) were observed in the EC patients and 13 (23%) in the control group (p < 0.0001). Observed and predicted deficits in the EC patients were 2.9% and 20.0% (p = 0.001), and for the control group 23% and 17.8% (p = 0.48). In considering EC and control patients (n = 115), variables associated with postoperative neurologic deficit were prolonged (>60 min) visceral aortic cross-clamp time (relative risk, 4.4; 95% CI, 1.2 to 16.5; p = 0.02) and lack of epidural cooling (relative risk, 9.8; 95% CI, 2 to 48; p = 0.005).Conclusion: EC is a safe and effective technique to increase the ischemic tolerance of the spinal cord during TA or TAA repair. When used in conjunction with a clamp-and-sew technique and a strategy of selective intercostal reanastomosis, EC has significantly reduced the incidence of neurologic deficits after TAA repair. (J Vasc Surg 1997;25:234-43.)

Purpose: Contrast arteriography (CA) is a useful but invasive technique for the preoperative evaluation of patients with abdominal aortic aneurysms (AAA). To evaluate the use of magnetic resonance arteriography (MRA) as a preoperative study we prospectively studied 38 patients undergoing AAA repair. Methods: All patients underwent biplane CA and MRA with use of a gadolinium-enhanced technique. Radiographic studies were then independently evaluated by blinded radiologists for anatomic findings with CA used as the standard. Studies were then independently evaluated by blinded vascular surgeons, and a surgical plan was made. Results: With CA and intraoperative findings as the standards, MRA proved highly accurate in the determination of multiple key anatomic elements. The proximal extent of aneurysmal disease was correctly predicted in 87% (33/38) patients. Significant iliofemoral occlusive disease was identified with a sensitivity of 83% (5/6). Iliac or femoral aneurysms were detected with a sensitivity of 79% (22/28) and specificity of 86% (41/48). Significant renal artery stenosis was detected with a sensitivity of 71% (12/17) and a specificity of 99% (72/73). Accessory renal arteries were correctly identified in 71% (12/17). Surgeon evaluators correctly predicted the proximal cross-clamp site in 87% (33/38) of patients with use of MRA as compared with the actual operative conduct. Proximal anastomotic sites were correctly predicted in 95% (36/38) with MRA and 97% (37/38) with CA. Renal revascularization was predicted by MRA with a sensitivity of 91% (10/11) and specificity of 100% (65/65). The use of bifurcated aortic prostheses was correctly predicted by MRA in 75% (12/16), which was similar to that predicted by CA (81%, 13/16). Conclusions: MRA can provide preoperative anatomic information that is equivalent to CA for surgical planning. Because of favorable cost and patient safety considerations MRA will assume increasing importance in the preoperative evaluation of AAA. (J VASC SURG 1995;21:891-9.)

The present report describes a patient with a traumatic pseudoaneurysm of the abdominal aorta and reviews the past literature. Traumatic aneurysms occur in a young patient population, and may present as late as 27 years after initial injury. Sonography and computed body tomograms (CBT) with contrast are especially useful screening tools. However, aortography is mandatory for complete preoperative evaluation. Aortic repair may require either suture aortorrhaphy, patch aortoplasty or graft replacement. Adequate exploration and repair at the time of initial injury will prevent pseudoaneurysm formation and the potential of delayed aortic rupture.

An aorto-caval fistula is a rare complication of an abdominal aortic aneurysm (AAA). Typical features, including congestive heart failure and a loud abdominal bruit, may be present and allow prompt diagnosis, but not infrequently they are absent or overlooked and the diagnosis not made preoperatively. Four patients with an AAA and an aorto-caval fistula are described, each of whom presented with hematuria. We believe the presence of hematuria in a patient with a symptomatic AAA should suggest the diagnosis of an aorto-caval fistula. A correct preoperative diagnosis may contribute to better planning of the operative procedure, reduced blood loss, and avoidance of possible pulmonary embolization.

• Transluminal angioplasty for the management of atherosclerosis obliterans has been performed in 160 patients for 100 iliac and 98 femoropopliteal lesions. The procedure was performed percutaneously except in eight patients in whom operative exposure was required. Angioplasty was technically successful in all 100 iliac artery lesions. There was hemodynamic and clinical improvement in 92 lesions. The procedure was technically successful in 84 of the 98 femoropopliteal artery lesions with hemodynamic improvement in 74 and clinical improvement in 78. There were ten complications directly related to the angioplasty and six related to the arteriographic procedure. Cumulative patency rates for the angioplasties were 92% and 75% at three years for iliac and femoropopliteal lesions, respectively. These promising results suggest that transluminal angioplasty has a definite role in the management of atherosclerosis obliterans of iliac and femoropopliteal arteries. (Arch Surg1982;117:1218-1221)

Angiosarcomas are rare tumors, particularly in the head and neck region. A case report of an angiosarcoma arising in the internal carotid artery is described; such an occurrence has not previously been reported. The etiology, pathology, and treatment of this unusual tumor are discussed.

A 9-year prospective study of 542 consecutive patients undergoing operation by one of the authors for abdominal aortic aneurysms was undertaken to define the incidence, clinical behavior, and anatomic characteristics of familial abdominal aortic aneurysms. Eighty-two (15.1%) patients having surgery for abdominal aortic aneurysms were found to have a first-degree relative with an aneurysm, as compared to nine (1.8%) of a control group of 500 patients of similar age and sex without aneurysmal disease (p less than 0.001). Detailed analysis was next performed of the pedigree charts of patients with a positive family history of aneurysm who underwent repair of abdominal aortic aneurysms by all authors over the 9-year study period. This review identified a total study population of 86 families with 209 first-degree relatives with abdominal aortic aneurysms. Clinical and anatomic features of this familial group were compared to those of 460 patients operated on for abdominal aortic aneurysms who had no family history of abdominal aortic aneurysms. Patients with familial abdominal aortic aneurysms were more likely to be women (35% vs 14%), and men with familial abdominal aortic aneurysms tended to be about 5 years younger than the women. There was no significant difference between the patients with nonfamilial and familial abdominal aortic aneurysms in anatomic extent of aneurysmal disease, multiplicity of aneurysms, associated occlusive disease, or blood type. There was a history of aneurysm rupture in 35 of 86 (40.7%) families with familial abdominal aortic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)