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Peripheral arterial disease (PAD) is the partial or total occlusion of peripheral arteries and is usually due to atherosclerotic disease. It can be diagnosed in a variety of ways; however it is objectively most commonly defined as an ankle-brachial index < 0.9. It results in a spectrum of manifestations ranging from asymptomatic disease, intermittent claudication, rest pain, tissue loss, to gangrene. Furthermore the presence of PAD is a coronary artery disease equivalent and puts patients at risk for cardiovascular and cerebrovascular complications and mortality. While PAD and diabetes share many risk factors, they also share the same endpoints; in fact the severity and progression of PAD are accelerated when associated with diabetes. Patients with diabetes are among those most vulnerable to developing PAD, and they suffer the most complications and worst outcomes, making early detection and risk factor modification paramount in their treatment.

Carotid artery stenosis predisposes to thrombo-embolization and stroke. Established tissue markers such as osteopontin, nitric oxide synthases, myeloperoxidases, and matrix metalloproteinases have been examined within stenotic plaques and their impact upon plaque stability discussed. However, a new generation of tissue markers is being discovered, and their role in atherosclerotic development and plaque stability is being debated. Prostaglandin synthase, 15-lipoxygenase-2, myeloid-related proteins 8 and 14, and protease nexin-1 have recently been shown to correlate with carotid artery atherosclerosis. These proteins highlight new areas of interest in the role of macrophages in atherosclerotic development, plaque formation, and rupture. Additionally, these new molecules raise the possibility of new screening and treatment techniques.

Poor arterial inflow continues to be a major contributing factor in the failure to heal diabetic foot wounds. Options for revascularization have significantly increased with the development of sophisticated endovascular techniques. However, the application of this technology is variable due to relatively little prospective, randomized data on newer techniques. Further, multiple specialties are capable of performing endovascular interventions and proper referral can be difficult. This article will review the basics of application of endovascular intervention in the diabetic patient with arterial disease and provide a broad understanding of the literature behind the decision-making on appropriate therapy.Keywords: endovascular; peripheral artery disease; revascularization; diabetic foot(Published: 1 October 2012)Citation: Diabetic Foot & Ankle 2012, 3: 18977 - http://dx.doi.org/10.3402/dfa.v3i0.18977

Infrainguinal arterial bypass (IGAB) surgery is commonly performed in patients with claudication, critical limb ischemia, or other arterial problems in the lower extremities. An IGAB is constructed from different materials depending on the anatomy of the lesion and the availability of an autogenous vein. The ideal material for IGAB is the greater saphenous vein, especially for distal below-knee bypass. In patients with no available autogenous vein, IGAB can be performed by using different prosthetic materials or biologic grafts. After the surgery, periodic surveillance is performed with duplex ultrasonography and clinical assessment of peripheral pulses and ankle-brachial indexes. If complications are detected, further work-up is performed with conventional arteriography, multidetector computed tomographic (CT) angiography, or magnetic resonance angiography. CT angiography has become a powerful tool for assessing the potential early and late complications of IGAB and for planning further therapy in a fast, reliable, and noninvasive manner.

The Clinical Practice Council of the Society for Vascular Surgery (SVS) was charged with providing an updated consensus on guidelines for hospital privileges in vascular and endovascular surgery. One compelling reason to update these recommendations is that vascular surgery as a specialty has continued to evolve with a significant shift towards endovascular therapies. The Society for Vascular Surgery is making the following four recommendations concerning guidelines for hospital privileges for vascular and endovascular surgery. First, anyone applying for new hospital privileges to perform vascular surgery should have completed an Accreditation Council for Graduate Medical–accredited vascular surgery residency and should obtain American Board of Surgery certification in vascular surgery within 3 years of completion of their training. Second, we reaffirm and provide updated recommendations concerning previous established guidelines for peripheral endovascular procedures, thoracic and abdominal aortic endograft replacements, and carotid artery balloon angioplasty and stenting for trainees and already credentialed physicians who are adding these new procedures to their hospital credentials. Third, we endorse the Residency Review Committee for Surgery recommendations regarding open and endovascular cases during vascular residency training. Fourth, we endorse the Inter-societal Commission for Accreditation of Vascular Laboratories (ICAVL) recommendations for noninvasive vascular laboratory interpretations and examinations to become a registered physician in vascular interpretation (RPVI) or a registered vascular technologist (RVT).

ObjectivesThis study examined the association of anatomic and temporal characteristics of graft-threatening lesions with the efficacy of percutaneous and open graft revision for failing infrainguinal vein grafts.MethodsConsecutive open and endovascular revisions for graft threatening lesions were reviewed. We evaluated graft durability and individual target lesion response to open and endovascular treatment to determine characteristics that may influence outcomes. Treatment failure was defined as target lesion restenosis or graft occlusion.ResultsEighty-four (58 endovascular, 26 open) infrainguinal vein graft revisions were performed in 67 failing, nonthrombosed infrainguinal vein grafts. Primary assisted graft patency at 5 years was 63% (95% confidence interval [CI], 46% to 77%). Follow-up was 29.5 ± 19.2 months. Grafts treated for early lesions (

We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric artery (IMA) and/or lumbar arteries (LAs) prior to endovascular abdominal aortic aneurysm (AAA) repair (EVAR). We retrospectively reviewed all patients undergoing EVAR over a 4-year period at one hospital. Results were analyzed using uni- and multivariate analyses. Fifty-five male patients with an average age of 71 years were evaluated. Follow-up averaged 15 +/- 13 months. The IMA was either coiled or occluded in 30 cases. One or more LAs were coiled in 29 patients. An average of 1.3 LAs per patients were coiled (range 0-6). There were no immediate or late complications from coiling. At last follow-up, 14 AAAs showed no change in diameter, one increased by 2 mm, and the remainder (n = 40) decreased by 7.5 +/- 6 mm in maximal diameter. Only five (9%) type 2 endoleaks were detected during follow-up. Three were associated with AAA size increase. Four of the five were treated with additional coiling, with good results. By logistic regression, neither endoleak occurrence nor AAA shrinkage correlated with LA or IMA coiling. However, by multivariate analysis, completeness of lumbar coiling correlated negatively with aneurysm shrinkage (p = 0.04) and IMA coiling correlated positively with aneurysm shrinkage (p = 0.04). Coil embolization of the IMA and/or LAs prior to EVAR can be safely accomplished in a large number of cases and is associated with a low incidence of type 2 endoleaks. We cannot at present demonstrate a benefit to LA embolization in terms of endoleak prevention or AAA shrinkage. However, IMA embolization may be of benefit in terms of AAA shrinkage.

The authors describe the case of a patient who developed a type-1 proximal endoleak 10 months after Ancure stent graft placement, despite the lack of stent migration or measurable neck dilatation. The patient had been under observation for a persistent type-2 endoleak and was noted to have an increase in his aneurysm size. The use of an uncovered stent was unsuccessful, and he required a covered proximal extension cuff. This led to a resolution of the endoleak. Implications in terms of surveillance and possible etiologies are discussed.

The objectives of this study were to define clinical outcomes following distal bypass graft occlusion in diabetic patients and identify factors predictive of limb loss. A retrospective review was conducted of all distal graft occlusions over a 5-year period in diabetic patients. Popliteal grafts, perioperative (30 days) failures, and redo distal bypasses were excluded. Eighty grafts were studied (43 cases done for ulcers, 31 for gangrene, and 6 for rest pain). Time to occlusion averaged 13 +/- 17 months post-bypass (median 6 months). Interventions following graft occlusion (lysis, thrombectomy, revision, or new bypass) were carried out in only 26 cases, leading to limb salvage in 11 cases (42%). This compares to a limb salvage rate of 54% in the 54 cases where no intervention was done ( p = NS). The overall amputation rate was 50% (14 AKAs and 26 BKAs). The interval between graft occlusion and amputation averaged 2 +/- 2 months. Limbs saved were followed an average of 14 +/- 11 months after graft occlusion. The presence of a foot wound (new or old) was associated with a higher likelihood of amputation (67% vs. 32% for cases with no foot wounds at the time of bypass failure; p0.005). In cases requiring an amputation, the toebrachial index averaged 0 +/- 0 post-bypass failure vs. 0.2 +/- 0.2 in cases where limbs were saved ( p0.05). Patients with congestive heart failure or who were nonambulatory at the time of graft occlusion were more likely to end up with an amputation ( p0.05). Limb loss was also more likely when gangrene had been the initial operative indication. No other factors were predictive of limb loss, including vein configuration, inflow or outflow level, prior bypass revision, known graft stenosis, time to occlusion, age, gender, other medical conditions, pre- or post-bypass ABI or TBI, graft velocities, or use of anticoagulants. Limb loss following primary distal bypass failure in diabetics is high. Repeat interventions have limited success. The findings justify aggressive programs of graft maintenance, and vigorous attempts at early closure of foot wounds.

The purpose of this multicenter study was to assess the long-term outcome of endovascular treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta on the basis of clinical and ultrasound examination. Clinical, ultrasound, and angiographic findings from 36 women and 50 men (mean age, 53.2 years) treated for atherosclerotic stenosis of the infrarenal abdominal aorta were reviewed. Patients had claudication in 74 cases and rest pain in 4. Seven patients presented trophic manifestations and one had blue toe syndrome. Mean preoperative systolic index was 0.71. Mean diameter reduction was 77%. Circumferential calcification was partial in 36 cases (41%) and complete in 30 cases (35%). Percutaneous transluminal angioplasty was performed using the single-balloon technique in 60 cases and double-balloon technique in 26 cases. A stent was placed in 76 cases (88%) by necessity in 34% of cases (22 residual stenoses, 4 dissections). Completion angiographic findings were considered good in 82 cases (95%). The remaining four patients had residual stenosis with a diameter reduction >30%. One patient died during the immediate postoperative period from septicemia unrelated to treatment (early mortality, 1.2%). Aortic angioplasty was complicated by stent detachment from the angioplasty balloon in two patients, retroperitoneal hematoma in one, peripheral embolism in two, puncture-site hematoma in three, myocardial infarction in one, and thrombophlebitis of deep femoral artery in one patient (early morbidity, 9.3%). All patients underwent follow-up with clinical and hemodynamic evaluation (mean follow-up, 31 months). Actuarial survival at 3 years was 91%. Primary actuarial patency was 94% at 1 year, 89% at 3 years, and 77% at 5 years. Aortic restenosis occurred in seven patients and was treated by angioplasty in two, aortobifemoral bypass in four, and surveillance in one. Mean systolic index was 0.89. Statistical analysis of patency demonstrated no factor predictive of long-term complication. From the long-term follow-up findings in this study, we conclude that aortic angioplasty is a reliable minimally invasive technique for treatment of isolated atherosclerotic stenosis of the infrarenal abdominal aorta.

Hispanic patients suffer from a high rate of leg amputations, far beyond what would be expected from the high prevalence of diabetes in this population. This raises questions about the efficacy of bypass operations across ethnic lines. We focused this review on dorsalis pedis bypasses, as these are frequently performed in diabetic patients. We compared outcomes between Hispanics and non-Hispanics and sought to identify factors predictive of failure or complications. The authors conducted a retrospective review of 144 dorsalis pedis bypasses in 106 men and 29 women with a mean age of 62 years. Eighty-two percent were Hispanic; 96% of cases were done for tissue loss, and 4% for rest pain. Twenty-five percent of patients experienced perioperative complications; these were more frequent in non-Hispanics than Hispanics (40% vs 22%, p = 0.05). The most frequent complications were wound related (11%). The 30-day mortality was 1.5% and 30-day graft thrombosis was 5%. Follow-up ranged from 1 to 62 months and averaged 12 months. Eighty-one percent of the limbs at risk were saved, although 36% of cases required minor foot amputations. Estimated primary graft patency was 68% at 30 months. The 30-month Kaplan-Meier curves for primary patency, assisted patency, and limb salvage were not statistically different between Hispanics and non-Hispanics (p > 0.4). Grafts that remained patent had higher duplex-derived intraoperative flow velocities in the dorsalis pedis artery than grafts that eventually failed (121 +/-69 vs 74 +/-26 cm/sec, p = 0.02). In grafts that remained patent, dorsalis pedis velocity decreased from the perioperative period to the 8 to 12 weeks time point, whereas no change was seen in grafts that eventually failed (mean decline of 48 +/-76 vs 1 +/-58 cm/sec, p = 0.02). No other factors were predictive of graft failure. The results of dorsalis pedis bypass in Hispanic patients compare favorably to those seen in other ethnic groups. This suggests that other factors must account for the high amputation rates seen in Hispanics, such as a frequent occurrence of nonreconstructible disease or unaccounted for cardiovascular risk factors. The usefulness of duplex-derived flow velocities in the dorsalis pedis to predict long-term graft patency warrants further investigation.

Objective: We graded the severity of occlusive disease in foot vessels of patients with diabetes and correlated the scoring obtained with graft patency and limb salvage. Methods: In this retrospective review of 199 limbs studied by means of angiography in 117 patients with diabetes mellitus, 124 limbs underwent bypass grafting. Each dorsalis pedis (DP), lateral plantar (LP), and medial plantar (MP) artery was assigned a score according to the reporting standards of the Joint Vascular Societies Council (0, no stenosis > 20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, < half the vessel length occluded; 3, > half the vessel length occluded.) A foot score (DP + MP + LP + 1) was calculated for each foot (1 to 10). The mean follow-up period was 14 months. Results: For all 199 limbs and for the 124 limbs that underwent bypass grafting, the mean scores were similar for the DP, MP, and LP (1.8 ± 1.0, 1.9 ± 1.0, 1.9 ± 1.0, respectively; P >.4). Only the MP and LP correlated with each other (r = 0.57; P

Purpose: To report the endovascular exclusion of an abdominal aortic aneurysm (AAA) in a patient with a horseshoe kidney and an isthmus mass with preservation of accessory renal vessels. Case Report: A 70-year-old man with a 5-cm AAA and renal cell carcinoma involving a horseshoe kidney was treated with an AneuRx bifurcated graft. Two accessory renal arteries believed to feed the isthmus mass were sacrificed, but 2 other accessory renal arteries from the left common iliac artery (CIA) were preserved by using an extension cuff to cover the aneurysmal left CIA distal to their origins. The right renal isthmus mass decreased in size on follow-up imaging. At 9 months, there was no endoleak evident on computed tomographic scans, and the aneurysm measured 4.8 cm. Conclusions: The presence of accessory renal arteries in AAA patients with horseshoe kidneys should not automatically exclude them from consideration for endovascular repair. Creative stent-graft arrangements can be a treatment option.

Revision of lower extremity bypass graft stenoses identified by surveillance duplex scanning is frequently required in diabetic patients. The authors evaluated (1) the value of routine angiography before graft revision in diabetics, (2) factors that predict patients in whom angiography alters management, and (3) the incidence of recurrent stenosis and factors that might predict it. Forty-two infrainguinal primary vein bypasses undergoing primary revision were retrospectively studied. The initial graft stenosis was detected at a mean of 1 1.5 ±3.6 months after the original bypass. Angiograms were obtained in 38 cases, revealing additional findings in 29 of 38 cases (76%), with a resultant alteration of the operative plan in 27 cases (71%). The most frequent additional angiographic finding was the identification or localization of a lesion in the inflow or outflow tracts (18 of 27 cases). Cases where the angiogram altered the management plan had a mean systolic velocity ratio across the stenosis (Vr) of 7.3 ±6.1, versus a Vr of 4.8 ±1.3 for cases where the angiogram did not alter the management plan (p < 0.04). Duplex scanning identified 4 lesions that were not seen on angiography; 3 of 4 were confirmed as webs at surgery. Twenty of 42 grafts (48%) developed recurrent stenoses at a mean of 4.9 ±3.8 months from initial revision. Restenosis occurred in 69% of female limbs as compared to 38% of male limbs (p = 0.06). Recurrent stenosis was not a predictor of ultimate graft failure, unless left untreated. Four of 10 untreated grafts ultimately failed. A total of 9 of the 42 grafts eventually failed (21%), leading to 3 amputations (7%). The authors conclude that failing infrainguinal bypass grafts identified by duplex in diabetics should undergo a detailed angiographic evaluation. This frequently leads to an alteration in the management plan, especially in the presence of a high Vr across stenoses. High rates of limb salvage (93%) and assisted primary graft patency (79%) despite a high recurrent stenoses rate (48%) justify routine duplex surveillance, preoperative angiography, and aggressive graft revision in diabetic patients with infrainguinal grafts.

The authors report their experience with 15 cases of groin complications associated with the use of percutaneous closure devices following femoral arterial catheterization over a 2-year period. The complication rate was 1.7% for catheterizations in which a closure device was used. The 15 cases included 7 uncomplicated pseudoaneurysms (PSA), 3 infected pseudoaneurysms, 4 nonarterial groin infections (infected hematomas and/or abscesses), and 1 case of femoral artery occlusion. These complications presented at an average of 5 ±4 days postcatheterization. One patient with an infected PSA required a below-the-knee amputation. During the same time interval, there were no infectious complications in patients not receiving closure devices. We conclude that groin complications associated with such devices tend to present late and include a higher percentage of infections as opposed to complications occurring in patients not receiving closure devices. An aggressive surgical approach to these problems appears warranted.

The authors report a patient who presented with a ruptured mycotic aneurysm that destroyed the posterior segment of the suprarenal perimesenteric aorta. Initial in-line repair with a rifampin-soaked Dacron prosthetic patch failed 14 days postoperatively with recurrent hemorrhage. At reoperation, the aorta was repaired with a superficial femoral/popliteal vein interposition graft; a segment of superficial femoral/popliteal vein was also used in-line to revascularize the superior mesenteric and celiac arteries. The patient survived with no evidence of recurrence at 8 months postoperatively.

A retrospective review of 101 diabetics without aortoiliac disease was carried out to analyze the ability of various noninvasive tests to predict the level of significant (>50% stenosis) infrainguinal arterial disease. Patients were studied with anklebrachial indices (ABI), toebrachial indices (TBI), segmental pulse volume recordings (PVR), segmental pressures (SEGP), segmental Doppler waveforms (DWF), and arteriography. Results were classified as normal, disease at the femoropopliteal level, infrapopliteal level, or both levels (multilevel), or noninterpretable. Our findings for the entire study showed that, as a single test, DWF appears to have the best angiographic correlation, although the summed diagnosis of combined DWF and PVR data is superior in distinguishing multilevel disease from isolated tibial disease. SEGP are of very limited use in diabetics, even in multimodality testing, and we no longer include that test in our routine evaluation of diabetics.

The efficacy of infrainguinal bypass for limb salvage in young diabetic patients has not been well established. The purpose of this study is to determine the intermediate-term results (patency and limb salvage) of infrainguinal revascularization carried out for limb salvage (rest pain or ulceration) in young (50 years old) diabetic atherosclerotic patients. Thirty-nine bypasses in 31 patients with a mean age of 44 years were retrospectively reviewed. There were no perioperative deaths. Minor or major complications occurred in 23% of cases. By life table analysis, the 18-month primary patency rate was 60+/-11%, assisted primary patency rate was 78+/-9%, and limb salvage rate was 71+/-9%. Most major amputations (five of nine) were required in patients with functional bypasses, either because of persistent infection or failure of wound healing. The presence of severe stenoses (70%) in all three major named foot vessels (dorsalis pedis, medial and lateral plantar arteries) was associated with a high likelihood of limb loss despite a patent bypass (p0.05). We could not identify any other factors statistically predictive of thrombosis, amputation, or the need for graft revision. Infrainguinal revascularization in this patient population can be carried out with acceptable limb salvage rates. However, patients should be made aware of the high incidence of amputation regardless of the success of the revascularization procedure, particularly in the presence of severe occlusive disease within the foot.

We report a case of a true plantar artery aneurysm in an adult. True aneurysms of the inframalleolar vessels are rare. The limited literature on the subject is reviewed, including differential diagnosis and suggested treatment. (J Am Podiatr Med Assoc 97(6): 480–482, 2007)

Rupture of an abdominal aortic aneurysm (AAA) is a significant cause of mortality in the United States. Often asymptomatic, AAA is considered a silent killer because it frequently remains undiagnosed until the time of rupture or the patient's death. Major risk factors, such as smoking, age, sex, race, and family history of aortic aneurysm, affect the formation of AAAs. National screening recommendations and advancements in treatment modalities during the past 20 years have improved morbidity and mortality, especially with the introduction of stent grafts for endovascular repair of the aorta. Endovascular aneurysm repair is less invasive than open surgical repair. This article describes the major risk factors, pathophysiology, and diagnosis of AAA; patient selection for endovascular repair; common adverse events and complications; and perioperative implications for the patient undergoing endovascular repair of an AAA. Knowing the treatment options for patients with AAA who are at high risk for rupture should allow clinicians to determine the best course of immediate and long-term care. Patients who undergo endovascular repair of an AAA should receive lifelong monitoring for complications, especially endoleaks.

Background: We have previously shown that preincubation of whole blood clots with recombinant tissue factor pathway inhibitor (rTFPI) attenuates clot-associated procoagulant activity assessed ex vivo. This study was undertaken to determine whether a single local application of rTFPI induces similar attenuation of the procoagulant activity on preclotted Dacron grafts implanted in an artery in vivo. Methods: Dacron grafts (4 mm × 4 cm long) were preclotted in porcine blood and incubated with either rTFPI (5 mg/ml) or arginine-phosphate buffer for 15 minutes. Grafts were implanted end-to-end in the femoral arteries of 10 pigs, with one rTFPI-treated and one buffer-treated graft implanted in each animal. Animals did not undergo anticoagulation either before or after graft implantation. Radiolabeled porcine fibrinogen was injected intravenously, and the grafts underwent perfusion for 1 hour. A subgroup of animals (n = 7) also had infusion of radiolabeled autologous platelets at the time of administration of radiolabeled fibrinogen. Results: Fibrin(ogen) deposition was decreased in rTFPI-treated grafts by 36% ± 7% (mean + SEM) compared with buffer-treated grafts (p = 0.001). Platelet deposition was also reduced in the rTFPI-treated grafts by 31% ± 15%, although the reduction did not reach statistical significance (p = 0.10). The extent of rTFPI-mediated attenuation of fibrin(ogen) versus platelet deposition varied independently among animals. Conclusions: Clot-directed anticoagulant effects of rTFPI appear to be useful for substantially decreasing the thrombogenicity of Dacron grafts immediately after their implantation. Chronic studies to determine whether the decreases in thrombogenicity result in improved long-term graft patency appear warranted.(J Vasc Surg 1996;24:865-70.)

To evaluate the procedure time, complications, and percutaneous dilational tracheostomy (PDT) charges.Operative data were prospectively collected for 356 PDTs including the initial series of 141 PDTs reported in 1994. Short- and long-term complications were retrospectively identified by review of medical records and patient telephone interviews.PDT was performed using the "Ciaglia" method of serial dilation over a Seldinger guidewire. Discharged patients (n = 258) were followed for a mean (+/-SD) of 10 +/- 7 months.The mean procedure time was 15 +/- 8 minutes; operative mortality rate, 0.3% (1/356); overall complication rate, 19% (69/356); long-term symptomatic tracheal stenosis rate, 3.7% (8/214). The mean total patient charge for bedside PDT was $1,370; for open tracheostomy in the operating room, $2,675.Surgeons can rapidly perform PDT at the bedside with a lower risk of complications than open tracheostomy and at a significantly reduced patient charge.

Basic-FGF (FGF2) is implicated as a regulator of smooth muscle cell proliferation that develops after arterial injury. Polyamines are essential for cell growth and differentiation and may mediate some of the FGF2-elicited responses. To examine this possibility, the effect of FGF2 on polyamine synthesis and uptake was tested on rat arterial smooth muscle cells. Exposure of cells to FGF2 for 24 and 48 h resulted in increased intracellular polyamine content. Ornithine decarboxylase (ODC) activity increased in FGF2-treated cells after 6 h of treatment, whereas no increases were detected in ODC mRNA steady-state levels. Basic-FGF increased maximal polyamine transport rate without changes in Km. Treatment with actinomycin D decreased polyamine transport. The effect of cyclohexamide on polyamine uptake was dose dependent. These studies indicate that treatment of vascular smooth muscle cells with FGF2 results in increases in intracellular polyamine content, polyamine synthetic activity, and polyamine tran...

We used serial weekly ultrasonography to prospectively screen 19 critically ill trauma victims for the development of biliary sludge. Fourteen patients had sludge formation during their hospitalization. Sludge development was positively associated with increased transfusion requirements, but not with any other laboratory or clinical findings, including injury severity scores. The enteral feedings administered to most patients did not prevent sludge formation in the majority of cases; all five patients receiving total parenteral nutrition had sludge. Three patients had complications that could possibly be attributed to the sludge (one case of acalculous cholecystitis and two cases of mild pancreatitis). No such problems occurred in the five patients who did not have sludge. No long-term clinical problems related to sludge have occurred. We conclude that gallbladder sludge frequently develops in critically ill trauma patients and that sludge may be associated with pancreatobiliary complications.

Percutaneous dilational tracheostomy (PDT) is a new technique that has been successfully performed in adult patients who required long-term mechanical ventilation, but it has not been used in children. The authors report their initial experience with PDT in 11 children and teenagers. The procedure is as follows. Using Seldinger's technique, the trachea is cannulated with a guide-wire. It is then progressively dilated, to an appropriately sized tract, with dilators from a commercially available kit. Then, a tracheostomy tube can be inserted into the trachea, loaded over a dilator. Eleven children, aged 10 to 20 years, underwent PDT in an average of 20 minutes. In eight cases, PDT was performed at the bedside. One intraoperative and one postoperative complication developed in the same patient; both complications were easily recognized and treated. Tracheal stenosis has not developed in eight decannulated patients at an average of 43 +/- 30 weeks after decannulation. PDT appears to be a safe, potentially cost-effective alternative to open tracheostomy in young patients.

Increased arterial wall polyamine content has been linked to intimal hyperplasia (IH) formation. Intracellular polyamine content may be regulated by a polyamine transmembrane transport mechanism, but the existence of such a system has not been demonstrated in systemic arterial smooth muscle cells. This study characterizes polyamine transport as found in rat aortic smooth muscle cells. Smooth muscle cells were isolated and cultured from Sprague-Dawley rat aortas. Polyamine transport was determined by adding [14C]-polyamines to the medium, calculating transport kinetic parameters, Vmax and Km. Competition studies with unlabeled polyamines and uptake in the presence of paraquat, a polyamine transport inhibitor, were done to test the specificity of the uptake system. We identified polyamine transporters in aortic smooth muscle cells which were temperature, concentration, and time dependent. Kinetic studies revealed that spermidine and spermine had greater affinity for the transporter(s) than putrescine (Km = 0.3, 0.3, and 3.7 microM respectively; P = 0.0001) while maximum uptake velocity was similar for all polyamines (26.6-31.0 pmole/mg protein/min). Inhibition of de novo polyamine synthesis upregulated polyamine transport 2.8-3.8 times (P = 0.0001) while transporter affinity (as reflected by Km) remained unchanged. Competition studies and paraquat treatment indicated the presence of two polyamine transporters: one shared by all polyamines, the other specific for spermine and spermidine. These data indicate that transmembrane polyamine transport occurs in arterial smooth muscle cells. Upregulation of this system may represent one control mechanism for IH development.

Tracheostomy is indicated frequently in the treatment of critically ill patients who require prolonged mechanical ventilation. The purpose of this prospective study was to evaluate our initial experience with 141 cases of percutaneous dilational tracheostomy (PDT) performed over a 2-year period. One hundred twenty PDTs (85%) were placed at the bedside, and 21 (15%) were performed in the operating room in conjunction with other procedures. The procedural complication rate was 11% (16 of 141). Most complications were easily recognized and did not preclude the completion of PDT. One death occurred secondary to severe bronchospasm. The postoperative complication rate was 8% (11 of 141). The most frequent complication was peristomal oozing. The average duration of follow-up after decannulation for patients discharged alive and decannulated was 36 +/- 27 weeks. There were 3 recognized cases of clinically symptomatic tracheal stenosis. We conclude that PDT is comparable with the open method and can be performed rapidly and safely at the patient's bedside.

A case in which the guidewire used to place a percutaneous jugular central line became entangled in the limbs of a Trapease inferior vena cava filter is presented. A 7F sheath introducer was fashioned into a monorail system to uncurl the wire's J tip and remove the wire without disturbing the filter's position. This report highlights an increasingly frequent clinical scenario and an inexpensive effective method for resolution.

Purpose: To report a technical modification that will prevent sheath kinking in acutely angled vessels during carotid stent placement. Technique: If a long vascular sheath kinks when engaging an acutely angled common carotid or innominate artery, the sheath is pulled caudally approximately 2 cm while a 0.014-inch guidewire, supported by a coronary balloon catheter, is advanced toward the internal carotid artery (ICA). Alternatively, to avoid kinking, the original 0.035-inch super stiff wire is maintained within the sheath until the 0.014-inch wire and coronary balloon have exited the sheath's distal tip. Conclusions: If an aortic arch is tortuous and the angle of the common carotid artery is unfavorable, a guiding catheter is preferable to a long vascular sheath for accessing the ICA during carotid stent procedures.

Wound complications involving large subcutaneous vessels can cause significant challenges for surgeons. Negative pressure wound therapy (NPWT) has been increasingly used for treating complex wounds in vascular surgery, including groin infections, either as a bridge to surgical closure or as a primary wound treatment modality. Although a growing body of evidence exists for managing various problematic wounds, such as diabetic foot ulcers and open abdominal wounds, the role of NPWT in wounds involving large blood vessels or wounds complicating infected vascular grafts has not been well defined. A multidisciplinary advisory panel reviewed the literature relevant to wounds related to vascular surgical procedures and complications, focusing on large subcutaneous or infected vascular conduits. The results supported by the literature and the clinical practice of the consensus panel suggested that NPWT can be a useful adjunct to the management of vascular groin infections and dehiscences but must be used with caution.

A group of international experts met in May 2006 to develop clinical guidelines on the practical application of vacuum assisted closure™ (V.A.C.(®)) therapy in deep sternal wound infections. Group discussion and an anonymous interactive voting system were used to develop content. The recommendations are based on current evidence or, where this was not available, the majority consensus of the international group. The principles of treatment for deep sternal wound infections include early recognition and treatment of infection. V.A.C. therapy should be instigated early, following thorough wound irrigation and surgical debridement. V.A.C. therapy in deep sternal wound infections requires specialist surgical supervision and should only be undertaken by clinicians with adequate experience and training in the use of the technique.

In 2004, a multidisciplinary expert panel convened at the Tucson Expert Consensus Conference (TECC) to determine appropriate use of negative pressure wound therapy as delivered by a Vacuum Assisted Closure device (V.A.C. THERAPY, KCI, San Antonio, Texas) in the treatment of diabetic foot wounds. These guidelines were updated by a second multidisciplinary expert panel at a consensus conference on the use of V.A.C. THERAPY, held in February 2006, in Miami, Florida. This updated version of the guidelines summarizes current clinical evidence, provides practical guidance, offers best practices to clinicians treating diabetic foot wounds, and helps direct future research. The Miami consensus panel discussed the following 12 key questions regarding V.A.C.(1) How long should V.A.C. THERAPY be used in the treatment of a diabetic foot wound? (2) Should V.A.C." THERAPY be applied without debriding the wound? (3) How should the patient using V.A.C. THERAPY be evaluated on an outpatient basis? (4) When should V.A.C. THERAPY be applied following revascularization? (5) When should V.A.C. THERAPY be applied after incision, drainage, and debridement of infection? (6) Should V.A.C. THERAPY be applied over an active soft tissue infection? (7) How should V.A.C. THERAPY be used in patients with osteomyelitis? (8) How should noncompliance to V.A.C. THERAPY be defined? (9) How should V.A.C. THERAPY be used in combination with other modalities? (10) Should small, superficial wounds be considered for V.A.C. THERAPY? (11) How should success in the use of V.A.C. THERAPY be defined? (12) How can one combine effective offloading and V.A.C. THERAPY?

The optimal management of complex proximal lower extremity vein injuries remains controversial. Ligation can be tolerated but is sometimes complicated by venous hypertension and possible limb loss. At the same time, the relatively large size of these proximal veins does not lend itself very well to the use of simple saphenous vein grafts, in cases when simple venorrhaphy is not feasible. We describe a case where the ipsilateral superficial femoral vein (SFV) was used as an interposition graft for repair of a complex gunshot induced common femoral vein (CFV) injury. Initial ligation was not tolerated clinically. This method of common femoral vein repair offers a durable autologous conduit that is less time consuming to perform than a panel or spiral saphenous vein graft.

Lower-limb peripheral arterial occlusive disease (PAOD) is a common cause of hospital admission among patients with diabetes. The authors conducted a study of 130 limbs in 68 patients with and without diabetes mellitus to evaluate the accuracy of methods used to screen for PAOD and peripheral neuropathy, including foot pulses and the ankle-brachial or toebrachial pressure index, and Doppler waveform analysis. They determined that the screening tools of foot pulses, toebrachial pressure index and qualitative waveform analysis were highly sensitive screening methods in patients as long as peripheral neuropathy was not present. Qualitative waveform analysis and the toe-brachial index were more effective in high-risk limbs with detectable peripheral neuropathy.

We report on a series of 10 consecutive cases of superficial femoral and popliteal artery atherectomy with the SilverHawk device, carried out for the treatment of peripheral vascular atherosclerosis. All cases were done with the use of a distal embolic protection device. Debris were retrieved in the filter in each case. Implications are discussed, along with a review of the available literature on this device.

Transmetatarsal amputation (TMA) is a durable reconstruction in the diabetic patient with limited forefoot gangrene. However, predicting TMA healing remains difficult. Our goals were to (1) determine the success rate of TMA and (2) identify factors predictive of TMA healing, in particular arterial foot anatomy. A retrospective review of all diabetic patients undergoing TMA was done. Blood supply to the foot was classified as mostly anterior (anterior tibial and/or dorsalis pedis artery), mostly posterior (posterior tibial or plantar arteries), or equally distributed (both systems patent or peroneal runoff). Foot vessels were assigned runoff scores from 0 to 3 according to Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. Forty-four TMAs in 29 men and 12 women were reviewed. Revascularization was done in 35 cases. In nine cases (20%), no bypass was deemed necessary (n = 7) or feasible (n = 2). Blood flow to the foot was deemed mostly anterior in 16 cases, mostly posterior in 17 cases, and equally distributed in 11. The TMA was left open in 19 cases and closed with staples or sutures in the rest. Limb salvage was achieved in 30 cases (68%) at a median follow-up of 48 weeks. Three of the four patients on dialysis required leg amputation (75%) vs. 11 of the 40 (27%) nondialysis patients (p = 0.05). When the TMA was left open, leg amputation was more likely (58%) than when closed primarily (12%) (p < 0.01). No angiographic factors were predictive of limb salvage. The need for revascularization was not associated with limb loss, although both patients with no feasible bypass option required below-knee amputation. TMA healing can be expected in a majority of diabetic patients after adequate revascularization but cannot be predicted by angiographic findings. Efforts should be made to achieve primary wound closure.

Screening for carotid artery disease in patients with systemic manifestations of atherosclerosis (e.g., peripheral vascular disease or coronary artery disease) has been recommended. We have been anecdotally impressed by what appears to be a unique atherosclerotic disease pattern in the Hispanic patient population of South Texas. To determine the prevalence of significant carotid artery disease in Hispanic patients with diabetes presenting with limb-threatening ischemia and to identify factors predictive of occurrence, we conducted a year-long prospective study of 92 consecutive patients undergoing infrainguinal bypass for limb salvage at The University of Texas Health Science Center in San Antonio. Peak systolic and end diastolic velocities in both internal carotid arteries were recorded by perioperative color duplex scanning. We found that the presence of a carotid artery stenosis did not correlate with any variables other than advanced age and presence of a bruit. Only 2 patients had a greater than 80% stenosis. We concluded that screening for carotid artery disease in diabetic Hispanics with critical lower extremity ischemia cannot be justified in younger patients. Even in patients older than 60 years, the presence of high-grade stenosis and, therefore, the need for carotid endarterectomy, is unlikely. However, screening in older patients is recommended to identify persons with moderate stenosis (peak systolic velocity greater than 175 cm/sec) whose disease is more likely to progress.

Infrainguinal angioplasty and stenting is becoming a more commonly performed procedure. Its durability remains a matter of debate, however. Aneurysmal degeneration following angioplasty and stenting is a complication not previously described in the literature with regard to the superficial femoral artery. We present a case in which two aneurysms of the superficial femoral artery developed following angioplasty and multiple-stent placements in a patient who had previously undergone a failed femoral-to-below-the-knee popliteal artery PTFE bypass graft. The patient presented to our institution with an occluded, infected bypass graft. He was treated with graft and femoral artery/stent excision and vein bypass grafting. A brief review of infectious complications after stent placement is included.

Recent reports have established the feasibility and safety of percutaneous transluminal angioplasty and stent placement in the treatment of innominate artery occlusive disease. Although the long-term durability of these endovascular approaches has not been clearly established, they are particularly attractive in patients who are not considered good candidates for surgical reconstruction. The authors present a case involving a morbidly obese Hispanic woman who had undergone previous coronary artery bypass and complained of right visual symptoms, dizziness, and right upper extremity claudication. Because of her unusual bovine anatomy and the desire to avoid reoperating in her chest, a unique approach with a left subclavian-to-carotid bypass and innominate artery angioplasty and stenting was used.

Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 +/- 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status (P0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics (P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level (P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA (P = 0.04). At an average follow-up of 10 +/- 8 months only 65 per cent were alive. Although 51 per cent were discharged to rehabilitation units only 26 per cent regularly wore a prosthesis with 23 per cent ambulating. BKA patients were more likely to ambulate than AKA (34% vs 9%; P = 0.001), and dialysis patients were less likely to ambulate than nondialysis patients (5% vs 25%; P0.02). During follow-up 17 per cent of patients discharged with an intact contralateral limb required amputation of that limb and 7 per cent had bypass surgery on that limb. Complication rates were higher in African Americans and Hispanics than in whites (59%, 45%, and 23%, respectively; P0.001), although mortality and ambulation rates were similar. Despite an acceptable perioperative mortality complication rates remain high especially in nonwhites. One-year mortality is high. Low rehabilitation rates especially in dialysis patients mandate further efforts in this regard. Vigilant follow-up of the contralateral limb is essential.

Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We wished to determine whether revascularization of chronically ischemic limbs results in any clinical changes in peripheral sensory thresholds. We prospectively measured quantitative vibration perception thresholds (VPT) using a Horwell neurothesiometer (in volts) in patients undergoing infrainguinal bypass, preoperatively and up to 6 month postoperatively. The bypassed limbs' preoperative VPT values were higher (lesser sensory perception) than the contralateral control limbs' preoperative values (mean score differences: 6 +/- 2 and 4 +/- 10 at toe and foot levels respectively; p ? 0.004). Preoperative VPT values were not different from the 6-month postoperative values for the revascularized legs at toe and foot levels for all 55 patients (mean score change of ?0.84 and ?1.32, p > 0.5). The contralateral limbs' VPT values did not change significantly over the 6-month period (mean change scores of 2.9, p > 0.15, and 2, p > 0.30, for toe and foot, respectively). A comparison of preoperative values between limbs that were eventually amputated and saved revealed no statistically significant differences. This study suggests that revascularization does not result in a clinically detectable improvement in sensory neuropathy. It may, however, prevent further degradation. The degree of preoperative neuropathy does not affect outcome in terms of limb salvage.

We report a rare case of primary aortoduodenal fistula (ADF) secondary to a Coxiella burnetii (Q fever) infection in a patient with an abdominal aortic aneurysm. A review of the available literature on the vascular complications of Q fever is presented. Q fever should be suspected in vascular patients with close animal contact when a standard infectious work-up is unrevealing. Diagnostic steps and management strategies for primary ADF are also briefly reviewed.

Thrombosed peripheral vessels that are pharmacologically or mechanically recanalized have diminished long-term patency rates compared with vessels that are repaired before occlusion. We hypothesized that thrombosis induces proinflammatory changes in the arterial media that may contribute to postthrombotic vascular remodeling.We studied expression of intercellular adhesion molecule (ICAM), a mediator of leukocyte recruitment, in the arterial wall after thrombosis. Thrombosis was induced in rabbit superficial femoral arteries by embolizing polystyrene beads (Thr-emb) or by ligation (Thr-lig). Control vessels were dissected but not ligated (C-dis) or were subjected to bead embolization and immediate removal (C-emb). Arterial wall ICAM expression was measured by indirect immunohistochemical analysis at 6 hours, 24 hours, and 1 week. Staining intensity was graded from 0 (none) to 4 (intense) by observers who were blinded to the experimental conditions.No increase in ICAM expression by thrombosed vessels was present at 6 hours. After 24 hours, ICAM expression in the media of thrombosed vessels was increased (Thr-emb, 2.3 +/- 0.5; Thr-lig, 2.0 +/- 0) compared with control vessels (C-dis, 0 +/- 0; C-emb, 0.8 +/- 0.5; p0.004). This difference became more marked at 1 week. ICAM staining localized to actin-staining regions of the media.Arterial thrombosis, but not surgical injury, induces pronounced early and sustained upregulation of ICAM expression in smooth muscle-containing regions of the arterial media. Upregulation of ICAM is likely to promote recruitment of inflammatory cells or mediate vascular remodeling after luminal thrombosis.