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Carotid angioplasty and stenting (CAS) has been proposed as a treatment option for carotid occlusive disease in high-risk patients including those with recurrent stenosis (RS) and contralateral occlusion (CO). This study reviews the results of carotid endarterectomy (CEA) in patients with RS and CO. We conducted a retrospective review from our vascular registry of 1670 patients who underwent CEAs (n = 1950) from January 1990 through December 2001. Procedures included RS 86 (4.4%), CO 112 (5.7%), and control 1752 (89.9%). There were 37 strokes in the entire group (1.9%). Among the high-risk group with RS and CO, there were 6 strokes, (RS n = 2, CO n = 4) 3%. There were 31 strokes in the control group 1.8% (p = NS). Postoperative TIAs were observed more frequently in patients with CO (n = 2) or RS (n = 2), 1.8% and 2.3%, respectively (p < 0.05). Neck hematomas, intracerebral hemorrhages, and myocardial infarctions did not differ between groups. Three deaths occurred within 30 days (0.15%); one was a patient with CO. Renal failure and symptomatic disease were each associated with a higher risk of perioperative stroke; among patients with renal failure there were 6 strokes (4.6%) p < 0.05, in symptomatic patients there were 26 strokes (2.7%) p < 0.05. Multivariate logistic regression analysis confirmed that preoperative renal disease and surgery for symptomatic disease were both significant predictors of perioperative stroke (p < 0.05; odds ratio 2.177 and 2.943 respectively) while neither RS nor CO was from these results we concluded that the presence of RS and CO do not increase the risk of perioperative stroke in CEA.

Objective Incidence of perioperative complications is increased and outcome is poor in young patients undergoing vascular surgery. We extensively reviewed results of lower-extremity procedures in this group of patients to further define the extent of short-term and long-term morbidity. Methods Results from our vascular registry were retrospectively reviewed for 76 lower-extremity revascularization procedures performed between January 1990 and May 2000 in 51 patients younger than 40 years. This represents 1.88% of 4052 lower-extremity bypass procedures performed during this period. Perioperative cardiac complications, long-term survival, graft patency, and limb salvage were evaluated. Kaplan-Meier curves were generated, and their significance was determined with the Cox-Mantel test. Results Forty-nine percent of patients were male, and 51% were female; mean age at presentation was 35.9 years (range, 27.5-39.8 years). Preoperative morbidity included diabetes mellitus (96.1%), smoking (70.6%), hypertension (78.4%), coronary artery disease (37.3%), hyperlipidemia (33.3%), and renal dysfunction (52.9%). Overall rate for 30-day postoperative mortality was 0.0%, for myocardial infarction was 0.0%, and for congestive heart failure was 1.32%. Thirty-day graft failure was 11.1% (n = 9). At 1 year, primary patency was 71.0%, secondary patency was 82.5%, and limb salvage was 87.1%; and at 5 years these rates were 51.9%, 63.4%, and 77.2%, respectively. After the initial surgery 11.8% (n = 6) of patients required at least one additional ipsilateral revascularization procedure, 31.3% (n = 16) required a bypass graft in the contralateral limb, and 23.5% (n = 12) ultimately required amputation. In patients who required additional ipsilateral procedures, 1-year primary patency rate was 66.7%, secondary patency rate was 62.5%, and limb salvage rate was 77.8%, compared with 5-year rates of 44.4%, 41.7%, and 64.8%, respectively, representing a decrease in patency compared with primary revascularization procedures. Overall survival at 1 year was 88.2%, compared with 73.3% at 5 years. Patients with preexisting renal disease had significantly decreased survival at 5 years compared with those without renal dysfunction (64.5% vs 82.6%; P = .019). Conclusions Our data suggest that age younger than 40 years is not associated with increased perioperative morbidity and mortality. However, these patients have a significant rate of early graft failure and dismal long-term survival, especially in patients with preexisting renal dysfunction. In addition, ipsilateral repeat operations have a marginal success rate.

Background Although evidence suggests that end-stage renal disease is associated with poor limb salvage and patient survival after arterial revascularization, little is known about the effect of renal transplantation. We analyzed the outcome in patients with renal transplants who underwent infrainguinal bypass procedures. Methods Data prospectively entered into our vascular registry were reviewed for all patients who underwent lower extremity bypass procedures from January 1, 1990, through January 31, 2002. Sixty patients were identified who had a functioning renal allograft at infrainguinal revascularization. Kaplan-Meier survival curves were generated for limb salvage, patency, and patient survival and were compared with the Mantel-Cox log- rank test. Results Sixty patients (40 men, 20 women; mean age, 47.1 years) underwent 76 bypass procedures in 71 limbs. Preoperative demographic data included diabetes (59 of 60 patients, 98.3%), coronary artery disease (26 of 60 patients, 43.3%), and preoperative serum creatinine concentration (SCr) greater than 2.0 mg/dL (9 of 60 patients, 11.7%). Mean follow-up was 25.1 months. Overall major complication rate was 11.8%, and 30-day mortality rate was 1.3%. Survival was 93.3% at 1 year and 66.6% at 5 years. Limb salvage was 87% at 1 year and 78% at 5 years. Primary graft patency was 78% at 1 year and 44% at 5 years. Preoperative SCr less than or equal to 2.0 mg/dL was associated with improved overall patient survival (5-year survival, 73.4% vs 37.5%; P = .01, log-rank test). Limb salvage and patency rates were not significantly affected by preoperative SCr greater than 2.0 mg/dL. Conclusions Lower extremity bypass can be performed safely and effectively in patients who have undergone renal transplantation. However, the importance of a well-functioning renal allograft at surgery is demonstrated by marked improvement in patient survival.

Mesenteric artery bypass originating from the supraceliac aorta (antegrade bypass) has been the standard orientation of visceral artery bypass grafts. Retrograde bypass, in which the bypass originates from the iliac arteries, has not been as widely accepted. The purpose of our study was to compare the results of these two types of bypass in a similar population. We retrospectively reviewed the records of patients undergoing mesenteric artery bypass at two tertiary care medical centers (UCLA Medical Center, Beth Israel Deaconess Medical Center). Between February 1992 and January 2001, 37 patients underwent 39 mesenteric bypass procedures. The choice of bypass orientation (antegrade versus retrograde) was determined by the individual surgeon. Chart review, duplex ultrasonography, and/or telephone interviews were used to assess symptom-free survival. Actuarial analysis was completed using Kaplan-Meier survival estimates. From this assessment we were able to determine that symptom-free survival of patients undergoing retrograde mesenteric bypass is similar to that seen in antegrade bypass. Primary retrograde bypass is a valid option for patients undergoing mesenteric bypass.

Objective: The purpose of this study was to review our experience over the last decade with the dorsalis pedis bypass for ischemic limb salvage in patients with diabetes mellitus. Methods: The study was a retrospective analysis of a computerized vascular registry and chart review. From January 10, 1990 to January 11, 2000, 1032 bypasses to the dorsalis pedis artery were performed in 865 patients (27.6% of the 3731 lower extremity arterial bypass procedures performed in that time period). Five hundred ninety-seven patients (69%) were male, with a mean age of 66.8 years. Ninety-two percent had diabetes mellitus. All procedures were done for limb salvage. Conduits included 317 nonreversed saphenous vein (30.7%), 273 in situ (26.4%), 235 reversed vein (22.8%), 170 arm vein (16.5%), 35 other vein (3.4%), and two polytetrafluoroethylene (0.2%) grafts. The inflow arteries were as follows: 294 common femoral (28.5%), 550 popliteal (53.2%), 114 superficial femoral (11%), and 74 other (7.2%). Results: The mortality rate within 1 month of surgery was 0.9%, and 42 grafts (4.2%) failed in the same interval, although 13 were successfully revised. In a follow-up period that ranged from 1 to 120 months (mean, 23.6 months), primary patency, secondary patency, limb salvage, and patient survival rates were 56.8%, 62.7%, 78.2%, and 48.6%, respectively at 5 years and 37.7%, 41.7%, 57.7%, and 23.8% at 10 years. Both polytetrafluoroethylene grafts failed in less than 1 year. Primary graft patency was worse in female patients (46.5% female versus 61.6% male at 5 years; P < .009) but better in patients with diabetes (65.9% diabetes mellitus versus 56.3% non-diabetes mellitus at 4 years; P < .04). Saphenous vein grafts performed better than all other conduits with a secondary patency rate of 67.6% versus 46.3% at 5 years (P < .0001). Multivariate analysis showed that length of stay greater than 10 days and dorsalis pedis bypass for the surgical indication of previous graft occlusion were independently predictive of worse graft patency at 1 year and use of saphenous vein as conduit was predictive of better patency. Conclusion: Dorsalis pedis bypass is durable with a high likelihood of ischemic foot salvage over many years. Saphenous vein is the preferred conduit when available. Short vein grafts from distal inflow sites are possible in more than 50% of cases. These results justify the routine use of pedal arterial reconstruction for patients with diabetes with ischemic foot complications. (J Vasc Surg 2003;37:307-15.)