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Background Combined heart and kidney transplantation ( HKT x) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long‐term survival after HKT x, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization. Methods and Results From June 1992 to December 2016, we performed 100 HKT x procedures. We compared older (≥60 years, n=53) with younger (50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15‐year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus P =0.45). There was no difference in 15‐year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P =0.95). Actuarial freedom from any cardiac rejection ( acute cellular rejection >0 or antibody‐mediated rejection >0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody‐mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKT x. There was no difference in the 5‐year survival among recipients by sensitization status with panel‐reactive antibody levels 50% (82±5.9%, 83±10.8%, and 92±8.0%; P =0.55). There was no difference in 15‐year survival after HKT x between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P =0.45). Conclusions HKT x is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel‐reactive antibody sensitization did not appear to affect survival after HKT x.

BACKGROUND: Studies show that alemtuzumab, a potent lymphocyte-depleting agent, is well tolerated in pediatric renal transplantation. We report on the use of alemtuzumab induction in highly HLA sensitized (HS) pediatric kidney transplant patients. METHODS: Fifty pediatric renal transplants were performed from 1/2009-12/2014. 15 HS patients received IVIG (2 g/kg ×2 doses)/rituximab (375 mg/m(2) ×1) for desensitization with alemtuzumab induction (15-30 mg, 1 dose, subcutaneous), whereas 35 nonsensitized patients received anti–IL-2R. Graft survival and infections were compared between 2 groups. RESULTS: All HS patients had received a prior transplant and were older with lower risk for viral infections due to serostatus. Patient survival was 100%, and graft outcomes were similar with mean 1-year creatinine of 1.03 ± 0.45 versus 0.99 ± 0.6 (P = 0.48). Although a higher incidence of acute cellular rejection was seen in HS patients receiving alemtuzumab (P = 0.001), there was a nonsignificant difference in antibody-mediated rejection. White blood cell and absolute lymphocyte count were significantly lower in alemtuzumab group at 30 days (P < 0.0001) and at 1 year (P = 0.026 and P = 0.001), respectively. There was no significant difference in bacterial, viral, or fungal infections after transplant. CONCLUSIONS: Alemtuzumab induction with desensitization led to nearly equivalent graft survival and functional outcomes in HS pediatric patients as nonsensitized patients receiving anti–IL-2R induction. With this small sample size, we observed significant reduction of white blood cell and absolute lymphocyte count up to 1 year posttransplant. The risk of infection was comparable between the 2 groups; however, patients who received alemtuzumab were older and at lower risk of viral infection due to serostatus.

Debido a la longevidad limitada y a la percepcion del mayor riesgo perioperatorio, en pacientes nonagenarios el tratamiento optimo de la estenosis carotidea significativa es motivo de controversia. El presente estudio se efectuo para evaluar nuestros resultados en este grupo demografico. Se llevo a cabo una revision retrospectiva de las endarterectomias carotideas (EAC) efectuadas en nonagenarios en el Cedars-Sinai Medical Center entre 1996 y 2006. Durante este periodo se efectuaron un total de 2.038 EAC en pacientes de todas las edades. Los datos extraidos incluyeron la demografia, factores de riesgo de los pacientes, indicaciones de la cirugia, complicaciones perioperatorias y supervivencia. Durante el periodo de estudio, como procedimiento primario, se efectuaron 53 (2,8%) EAC en 49 pacientes de 90 anos o mayores. De estos, 11 (22,4%) eran diabeticos, 38 (77,5%) eran hipertensos, y 31 (63,3%) presentaban estenosis de la arteria carotida. En 11 pacientes (22,4%) se identificaron antecedentes de tabaquismo y no habia fumadores actuales. En tres (6,1%) estaba presente una nefropatia, y uno de ellos era dependiente de la dialisis. La duracion media de la estancia hospitalaria despues de la cirugia fue de 3,4 ± 4,3 dias. Requirieron ingreso en la unidad de cuidados intensivos tras cirugia cinco pacientes (10,2%). No se produjeron ictus postoperatorios y ninguno de ellos habia experimentado un ictus homolateral durante el seguimiento. Un paciente (1,8%) experimento un infarto de miocardio y otro fallecio en el periodo perioperatorio (1,8%). Las tasas de ictus y mortalidad a 30 dias no difirieron significativamente de las de pacientes menores de 90 anos de edad, siendo del 0,3% y 0,4%, respectivamente (p = no significativa mediante la prueba exacta de Fisher). Utilizando el analisis de las tablas de vida de Kaplan-Meier, las tasas de supervivencia a 1 y 5 anos fueron del 84 ± 5% y del 33 ± 9%, respectivamente. El presente estudio demuestra que en un grupo de nonagenarios seleccionados apropiadamente, la EAC es un procedimiento sin riesgos con una morbilidad perioperatoria aceptable.

En raison d'une longevite limitee et de la perception d'une augmentation du risque peri-operatoire, le traitement optimal des stenoses carotidiennes significatives chez le nonagenaire reste controverse. Cette etude a ete realisee pour evaluer nos resultats dans ce groupe demographique. Une etude retrospective a ete realisee des endarteriectomies carotidiennes (EC) realisees chez des nonagenaires au Cedars-Sinai Medical Center entre 1996 et 2006. Au cours de cette periode, 2.038 EC ont ete realisees chez des malades de tous âges. Les donnees etudiees concernaient la demographie, les facteurs de risque des malades, les indications operatoires, les complications peri-operatoires et la survie. Cinquante trois EC (2,8%) ont ete realisees comme intervention principale chez 49 malades âges de 90 ans ou plus au cours de la periode d'etude. Parmi ces malades, 11 (22,4%) etaient diabetiques, 38 (77,5%) etaient hypertendus et 31 (63,3%) etaient coronariens. Onze malades (22,4%) avaient des antecedents de tabagisme et il n'y avait aucun fumeur actif. Une insuffisance renale chronique etait presente chez trois malades (6,1%) dont un etait dialyse. La duree mediane de sejour a ete de deux jours avec des extremes de 1 et 24 jours. Cinq malades (10,2%) ont necessite un sejour en unite de soins intensifs apres l'intervention. Il n'y a eu aucun accident vasculaire cerebral post-operatoire et aucun malade n'a eu d'accident vasculaire cerebral homolateral au cours du suivi. Un malade (1,8%) a fait un infarctus du myocarde post-operatoire. Un malade est decede au cours de la periode post-operatoire (1,8%). Les taux d'accident vasculaire cerebral et de mortalite a un mois ne differaient pas significativement par rapport a ceux des malades âges de moins de 90 ans (0,3% et 0,4% respectivement, p = non significatif par le test exact de Fisher). En utilisant l'analyse actuarielle de Kaplan-Meier, les taux de survie a un et 5 ans etaient respectivement de 84 ± 5% et 33 ± 9%. Notre travail demontre que dans un groupe de nonagenaires, l'EC est une intervention sure avec une morbidite peri-operatoire acceptable.

Because of limited longevity and perceived increased perioperative risk, the optimal treatment of significant carotid stenosis in nonagenarians is controversial. This study was conducted to evaluate our results in this demographic group. A retrospective review was performed of carotid endarterectomies (CEAs) done in nonagenarians at Cedars-Sinai Medical Center between 1996 and 2006. During this period, a total of 2,038 CEAs were performed on patients of all ages. Data abstracted included demographics, patient risk factors, indications for surgery, perioperative complications, and survival. Fifty-three (2.8%) CEAs were performed as the primary procedure on 49 patients aged 90 or greater during the study period. Of these patients, 11 (22.4%) had diabetes, 38 (77.5%) had hypertension, and 31 (63.3%) had coronary artery disease. Eleven patients (22.4%) had a history of smoking, and there were no current smokers. Renal disease was present in three (6.1%) patients, one of whom was dialysis-dependent. The median length of stay was 2 days with a range of 1 to 24 days. Five patients (10.2%) required the intensive care unit following surgery. There were no postoperative strokes, and none of the patients had suffered ipsilateral stroke during follow-up. One patient (1.8%) had a perioperative myocardial infarction. One patient died in the perioperative period (1.8%). The 1-month stroke and mortality results did not differ significantly from those in patients under the age of 90, 0.3% and 0.4%, respectively (p = nonsignificant by Fisher's exact test). Using Kaplan-Meier life-table analysis, the 1- and 5-year survival rates were 84 +/- 5% and 33 +/- 9%, respectively. Our study demonstrates that in a group of well-selected nonagenarians, CEA is a safe procedure with acceptable perioperative morbidity.

The hyperperfusion syndrome is a rare delayed postoperative complication of carotid endarterectomy (CEA) characterized by headache and seizure, with or without intracranial edema or hemorrhage. Between January 1996 and December 2003, 1,602 CEAs were performed. Six patients (0.4%) developed symptoms of hyperperfusion within 2 weeks of surgery. All patients had critical stenoses, fiveor =90% and one 80-90%, with poor backbleeding from the distal internal carotid artery noted at operation in all cases. Five patients were asymptomatic prior to operation; one had a hemispheric transient ischemic attack. Three patients had severe contralateral internal carotid disease (two occlusions and one severe stenosis). Two patients developed severe, self-limiting headache that prolonged hospitalization. Three patients had ipsilateral intracranial bleeding, two occurring after an uneventful postoperative course. After initial discharge from the hospital, severe intracranial hemorrhage caused death in two patients. One patient experienced focal seizures 1 week after discharge. Hypertension did not appear to be related to the symptoms in any case. During the study period, the hyperperfusion syndrome caused three of five perioperative strokes (60%) and two of seven deaths (29%) in the entire endarterectomy population. Although rare, the hyperperfusion syndrome accounts for a significant percentage of the neurological morbidity and mortality following CEA.

Introduction: Arterial dissection commonly affects the thoracic aorta and is associated with high morbidity and mortality rates. Although dissection of the abdominal aorta is considered rare, liberal use of diagnostic computed tomographic scan imaging for evaluation of abdominal pain has identified this process with increasing frequency. Because the clinical features and therapeutic options of isolated abdominal aortic dissection are not well characterized, we reviewed our recent experience and provide an algorithm for treatment. Patients and Results: Since 1996, we have treated 10 patients with abdominal aortic dissection. The mean age was 62 ± 17 years, and 40% were female. Presentation included abdominal pain in seven patients and lower extremity ischemia in one patient. Dissection was asymptomatic in two of the patients. Hypertension, smoking history, remote trauma, and claudication were noted in four, three, two, and two of the patients, respectively. Three patients had abdominal tenderness, three had a pulsatile mass, and five had a benign abdominal examination. The diagnosis of dissection was made on abdominal computed tomographic scan in eight cases, on arteriogram in one case, and at operation in one case. No patient had an associated thoracic aortic dissection. The dissection flap originated below or at the renal arteries in nine of the cases and at the superior mesenteric artery in one case. Length of the dissection ranged between 21 and 110 mm, and in three patients, the dissection flap extended beyond the aortic bifurcation into the common iliac arteries. In three patients who had an aortogram, evidence of flow limitation was found on the basis of the presence of aortic stenosis or occlusion. Treatment consisted of aortic stent graft deployment in one patient, direct aortic reconstruction in three patients, and observation in the remaining six patients. Conclusion: Although the natural history of isolated abdominal aortic dissection has not been well defined, our experience adds to the understanding of this rare process. Because aneurysmal degeneration can occur, close surveillance is indicated if definitive treatment is not used initially. Patients with ischemic symptoms and those with intractable pain need intervention, the nature of which should be based on risk profile and aortoiliac anatomy. (J Vasc Surg 2002;36:205-10.)

ABMR remains a significant concern for early graft loss, especially for those who are HS against HLA antigens. We sought to determine the risk factors leading to ABMR in HS pediatric kidney transplant recipients. From January 2009 to December 2015, 16 HS pediatric kidney transplant patients at our center (age range 2-21) were retrospectively reviewed for outcomes and risk factors for ABMR. All HS patients received desensitization with high-dose IVIG/rituximab prior to transplant. Two groups were examined: ABMR+ (n = 7) and ABMR− (n = 9). Patient survival was 100%; however, one patient in the ABMR+ group suffered graft loss from ABMR 16 months post-transplant. ABMR+ patients had higher Class I PRA at the time of transplant (Class I: 73.1 ± 19.1 vs 49.1 ± 28.3, P = .075), although not statistically significant. ABMR+ patients were more likely to have a history of transplant nephrectomy (P = .013). The characteristic that most strongly correlated with ABMR was the DSA-RIS (P = .045), a scoring system used to quantify cumulative intensity of all DSA. In conclusion, DSA, as quantified by the RIS at the time of transplant, should be considered as part of the initial allocation strategy and patients with high RIS monitored closely for ABMR post-transplant.

Hemosuccus pancreaticus—blood entering the gastrointestinal tract through the pancreatic duct—is a rare and elusive form of gastrointestinal bleeding. The most common cause is a splenic artery pseudoaneurysm caused by acute or chronic inflammation of the pancreas. We report the case of an 86-year-old woman who had recurrent gastrointestinal bleeding from erosion of an aneurysm of the splenic artery into the pancreatic duct. The lack of associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Nonresective treatment by ligation of the splenic artery proximal and distal to the aneurysm prevented any additional bleeding. Postoperative technetium sulfur colloid scanning demonstrated normal perfusion of the spleen. Only 16 cases of hemosuccus pancreaticus from primary splenic artery disease have previously been reported in the English-language literature (15 primary aneurysms, one medial disruption without an aneurysm). In contrast to cases caused by inflammatory pseudoaneurysms, splenic artery - pancreatic duct fistulas caused by primary aneurysms of the splenic artery should be treated without pancreatic or splenic resection, either with surgery or by embolization. In elderly patients with recurrent gastrointestinal bleeding of obscure source, the differential diagnosis should include the possibility of a ruptured aneurysm communicating with a viscus. (J VASC SURG 1994;19:158-64.)

Purpose: Vascular clamps, vessel loops, and intraluminal occluding devices used to control tibial and pedal vessels can be injurious and may fail to occlude heavily calcified arteries. In an effort to prevent injury to these small arteries, we have investigated the safety and efficacy of thigh pneumatic tourniquet occlusion for distal vascular control during infrapopliteal reconstruction. Methods: During an 18-month period, 88 tibial or pedal arterial reconstructions were performed on 80 patients (mean age 75 years) by the tourniquet technique. Data regarding indications for operation, preoperative evaluation, intraoperative findings, surgical technique, and early outcome were recorded prospectively. Results: Sixty percent of patients were diabetic: 36% insulin dependent and 24% non-insulin dependent. The indications for operation were claudication in 6 (7%), ischemic ulcer in 24 (27%), rest pain in 25 (28%), and gangrene in 33 (38%) patients. Thirty-five percent of operations followed failed ipsilateral infrainguinal reconstructions. The peroneal artery was the target vessel in 38%, anterior tibial in 26%, posterior tibial in 23%, tibioperoneal trunk in 9%, and inframalleolar vessels in 4% of cases. Preoperative analog waveforms and ankle-brachial indexes were used to classify the tibial arteries as compliant, 49%; relatively noncompressible, 30%; and absolutely noncompressible, 9%. Twelve percent had no Doppler flow at the ankle level. At operation 36 of the target arteries (41%) had mural calcification. Tourniquet pressures of 200 to 400 mm Hg (mode 250 mm Hg) were applied from 13 to 55 minutes (mean 27.1 ± 9.1 minutes). All patients were given systemic anticoagulants. In 19 limbs (22%) the tourniquet was used to occlude a patent superficial femoral artery above the proximal (inflow) anastomosis to either the superficial femoral artery (8%), the above-knee popliteal artery (5%), or the below-knee popliteal artery (9%). Hemostasis was adequate in all cases and no alternative occlusive devices were required. There were no significant complications attributable to the use of the pneumatic tourniquet. Conclusion: Tourniquet occlusion simplifies the infrapopliteal dissection, lessens operating time, improves visualization of the distal anastomosis, and removes the potential for arterial injury to the target vessel. Arterial calcification and noncompressible tibial arteries do not contraindicate the use of thigh tourniquet occlusion. This technique is preferred for all patients undergoing tibial or pedal artery reconstruction. J VASC SURG 1993;18:637-47.)

The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. Complications included ischemia (25%), bleeding (2%), lymph fistula (1%), and femoral neuropathy (1%). Twenty patients required 1 or more surgical interventions for lower extremity vascular complications. The majority of patients who underwent operation (70%) had significant pre-existing arterial occlusive disease. Local femoral artery reconstruction or repair was performed in 18 patients. Two patients had adjunctive bypasses. Continued IABP support was required in four patients after treatment of complications. One patient (1%) had an above-knee amputation. Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.

We implanted 112 glutaraldehyde-fixed bovine carotid artery grafts (BioPolyMeric™ [BPM]) for infrainguinal reconstruction in 107 legs of 98 patients. Indications for surgery were disabling claudication in 28%, rest pain in 33% and tissue loss in 39%. In 32%, BPM bypass followed failed ipsilateral reconstruction. Autologous vein was either absent or inadequate in 60% of cases. BPM was used preferentially over vein in above-knee bypasses. The distal anastomosis was to the above-knee popliteal artery in 40%, to the below-knee popliteal artery in 35%, and to the tibial arteries in 25%. Follow-up was available from one to 25 months, with a mean of nine months. Wound complications developed after 9% of operations, including seven (6%) graft infections. Both patent grafts that became infected were salvaged. Four patients (4%) died within 60 days of surgery due to cardiac complications. Life-table primary and secondary patencies of all grafts were 64% and 65% at one year, and 48% and 62% at two years, respectively. The only factor significantly affecting graft patency was the location of the distal anastomosis (p

The records of 146 patients 80 years of age or older who underwent 183 carotid endarterectomy operations from 1964 through 1990 were reviewed to determine surgical risk. The indications for operation were asymptomatic patients with carotid stenosis (n = 36); ipsilateral transient ischemic attacks (n = 46); ipsilateral stroke (n = 28); ipsilateral retinal embolus (n = 15); nonlateralizing symptoms (n = 40); and asymptomatic side in patients with contralateral symptoms (n = 18). Postoperatively, three patients (1.6% of operations) had a stroke with a residual deficit and three (1.6%) died. All deaths were from myocardial infarction. For comparison, during the same time period, the combined stroke with residual deficit and death rate for patients less than 80 operated upon for similar indications was 3.5%. Since 80-year-old patients have a life expectancy of at least five years, the authors conclude that elderly patients should be evaluated for carotid endarterectomy using criteria similar to that used for younger patients.

In an effort to eliminate the inherent neurologic morbidity associated with arteriographic investigation, we have increasingly relied upon duplex scans of the extracranial carotid arteries prior to endarterectomy. The percentage of patients undergoing carotid endarterectomy without arteriograms has increased from 5% in 1984 to 69% during 1988-1989. Initially, carotid endarterectomy without arteriography was limited to patients with hemispheric symptoms and relative contraindications. Over the course of the study from 1984-1989, indications for operation were similar for patients having carotid endarterectomy on the basis of duplex scan alone or following arteriography. The perioperative outcome for these patients undergoing duplex scan (n = 255) and arteriography (n = 484) were similar for stroke (2.4%) versus 2.7%, p = NS) and death (0% versus 0.4%, p = NS). Stratification of groups by indication did not show any significant differences in outcome. Duplex scans were sufficiently accurate to replace preoperative arteriograms in identifying significant stenoses at the carotid bifurcation, including asymptomatic disease. Lack of information regarding intracranial arterial occlusive disease did not adversely affect perioperative outcome. Carotid arteriography can be used selectively when duplex scans are technically difficult, when physical examination or scans suggest either inflow (arch) disease or diffuse, distal internal carotid plaque, or when cerebral symptoms are not sufficiently explained by duplex findings.

The influence of neutralizing or not neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma is unknown. During the past 6 years some of the authors frequently gave protamine sulfate to neutralize heparin, whereas others did not unless a patch was used or wound hemostasis was not readily obtained. To determine the influence of protamine sulfate on stroke and wound hematoma the records of 697 patients having a carotid endarterectomy from January 1984 to September 1989 were reviewed. Protamine sulfate was given to 328 patients, and 369 did not receive protamine sulfate. The incidence of stroke in the two groups was 1.8% (n = 6) and 2.7% (n = 10), respectively, and the difference was not significant (p = 0.6019). Excluding three strokes that could not be related to neutralizing or not neutralizing heparin, the difference remained insignificant (1.5% vs 2.2%, p = 0.7290). The incidence of wound hematoma was 1.8% (n = 6) in patients given protamine sulfate and 6.5% (n = 24) in patients not given protamine sulfate, and this difference was significant (p = 0.0044). The difference remained significant when three hematomas not related to protamine sulfate were excluded (1.2% vs 6.2%, p = 0.0013). In patients not given protamine sulfate draining the wound lessened the incidence of wound hematoma (4.4% vs 8.6%), but this difference was not statistically significant (p = 0.1475). In patients given protamine sulfate the dose of protamine sulfate (15 to 45 mg vs 50 to 75 mg) had no statistically significant effect on the incidence of stroke (0.8% vs 2.0%, p = 0.6530) or wound hematoma (1.6% vs 1.0%, p = 1.000).

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.

Spontaneous infrarenal abdominal aortic dissection (SIAAD) is rare. Patients with SIAAD may be asymptomatic or may present with abdominal pain or lower extremity ischemia. We describe a case report of a patient with SIAAD who presented with claudication. We reviewed the English literature on this disorder and specifically evaluated the differences between patients on the basis of their presenting symptoms. Patients who had SIAAD and lower extremity ischemia were more likely to have the dissection process extend into the iliac or femoral artery and were less likely to have an associated abdominal aortic aneurysm. Aortic rupture in the presence of SIAAD was associated with increased risk of death.

Introduction Cryopreserved saphenous vein allografts (Cryograft; CryoLife, Kennesaw, Ga) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Although some studies of Cryografts report poor long-term patency, an anticoagulation protocol may improve outcome. We evaluated our experience with Cryografts to further define their role in lower extremity revascularization. Patients and methods Between March 1992 and March 2002, 240 infrainguinal revascularization procedures with Cryografts were performed in 199 limbs of 177 patients. Eighty-nine percent of procedures were performed because of ischemic rest pain or tissue loss, and 75% of vein grafts were implanted into infrapopliteal targets. Most patients received anticoagulation therapy with warfarin sodium or aspirin, or both, postoperatively. Mean age of the cohort was 78 years; 61% were women; 75% had hypertension, 58% had diabetes, and 38% had renal dysfunction; and 47% were current or past smokers. Results Mean follow-up was 7 months (range, 0-48 months). Primary patency rate was 83% at 1 month, 50% at 6 months, 30% at 12 months, and 18% at 24 months. Diabetes adversely affected graft patency. Warfarin sodium or antiplatelet therapy did not significantly improve graft patency. Limb salvage was 80% at 1 year and 71% at 2 years. Conclusions Cryografts have low primary patency rates that are not affected by anticoagulation with warfarin sodium. Short-term patency of these grafts may be sufficient to heal ischemic wounds and thereby prevent limb loss. However, other less expensive alternatives, eg, prosthetic grafts with vein cuffs, are available and appear to have better patency. Accordingly, use of Cryografts should be limited to revascularization through infected fields in patients without autogenous conduit.

Carotidynia is a term that is best defined by neck pain associated with tenderness over the carotid artery. The differential diagnosis of this entity is broad and includes vascular disorders such as carotid dissection, aneurysm, occlusion, and arteritis. We describe the first reported case of carotidynia caused by septic embolization to the carotid bulb and offer a logical plan for its management.

Transvenous placement of inferior vena cava (IVC) filters has become commonplace in selected patients with deep venous thrombosis (DVT) and pulmonary embolism (PE). IVC filters have been shown to have excellent therapeutic efficacy and low complication rates. Penetration of the IVC by filter hooks or struts has been reported and commonly noted to be inconsequential. We report a laceration of a lumbar artery by a stainless steel Greenfield (SSG) filter strut that resulted in a near fatal hemorrhage, and review the world literature on caval perforation by IVC filters.

From 1964 through 1991 we performed primary closure of the arteriotomy in 1173 patients and patch angioplasty in 506 patients after carotid endarterectomy. The decision to patch was made at the surgeon's discretion. In general a patch was used for small arteries. In the primary closure group 32 patients (2.7%) had a perioperative stroke and in the patch angioplasty group 17 (3.4%) had a stroke. The difference (2.7% vs. 3.4%) was not significant (p

Visceral artery aneurysms are uncommon lesions that are rarely identified in the absence of symptoms. Between February 1972 and April 1992, nine patients (5 men and 4 women) with rupture of visceral artery aneurysms were treated. The average age was 62 years old (range 39 to 86 years old). The arteries involved were the splenic (4), the common hepatic (2), the left hepatic (1), the celiac (1), and the superior mesenteric (SMA) (1). No ruptured renal artery aneurysm was identified. Six patients presented with abdominal distension, pain, and hemodynamic instability. Three patients had recurrent gastrointestinal bleeding with erosion into the duodenum, the common bile duct or the pancreatic duct. All three had unnecessary gastrointestinal operations despite preoperative (2 patients) or intraoperative (1 patient) identification of a visceral artery aneurysm. One patient with an SMA aneurysm had ligation and bypass. Three patients with splenic artery aneurysms had splenectomy. The remaining five patients had either ligation or resection without arterial reconstruction. No end-organ dysfunction was identified. There was one death (11%) due to the SMA aneurysm. Pathological findings in four patients were cystic medial necrosis, diffuse deficiency of the internal elastic lamina, fibromuscular dysplasia, and atherosclerosis, respectively. The remainder were thought to be due to atherosclerosis on gross examination. Rupture of visceral artery aneurysms occurs infrequently and can be treated by simple ligation in most cases. Recognition that rupture of splanchnic arterial aneurysms into adjacent viscera can cause recurrent gastrointestinal bleeding may prevent both substantial delays in diagnosis and inappropriate therapy.

Purpose: This study was undertaken to compare repeat percutaneous transluminal angioplasty (rPTA), arterial reconstruction, and noninvasive therapy for treatment of patients with recurrent stenosis after PTA of the superficial femoral or popliteal artery. Methods: From 1983 to 1993, 93 patients were treated for recurrent femoropopliteal stenosis. Indication for treatment was claudication in 72 patients, rest pain in 9, and ischemic ulcer in 12. Thirty-six patients (38%) were treated with arterial bypass, 35 (38%) with rPTA, and 22 (24%) with exercise and medication. Patients were monitored with clinical examination, ankle-brachial indexes, and duplex scanning. Follow-up ranged from 6 to 110 months (mean 42 months). Results: With life-table analysis, the clinical and hemodynamic success of patients treated with rPTA was 41% at 1 year, 20% at 2 years, and 11% at 3 years. For patients treated with arterial bypass, the primary graft patency rate was 84%, 72%, and 72% at 1, 2, and 3 years, respectively. The secondary graft patency rate was 94%, 88%, and 88% at the same intervals. All patients with patent grafts were symptom free. All 22 patients treated with noninvasive therapy continued to have symptoms, but none required amputation during follow-up (range 6 to 108 months). Overall, patients with claudication did better than those treated for rest pain or an ischemic lesion after either rPTA or arterial bypass, but no other variable was statistically significant in predicting outcome. Conclusions: This study finds that arterial bypass is safe and more effective than rPTA in treating patients with recurrent stenosis. Preoperative evaluation is unable to select patients likely to benefit from rPTA. Repeat PTA should be reserved for patients with limited life expectancy or contraindications to operation. (J VASC SURG 1994;20:577-87.)

Acute renal allograft vein thrombosis is a rare but serious complication of renal transplantation. When occurring in the early posttransplant period it is usually associated with surgical complications and often results in the loss of the graft. At later stages, when graft function has stabilized, its development may then be associated with underlying disorders such as glomerulonephritis, immunosuppressive therapy, increased hematocrit, acute rejection, or extension of lower extremity venous thromboses. We report a case of acute allograft dysfunction occurring in the setting of extensive deep vein thrombosis. In our patient, thrombosis in the setting of acute graft tenderness and swelling, anuria, and an increasing creatinine strongly suggest a diagnosis of acute allograft renal vein thrombosis. We describe a successful reversal of acute renal failure through urokinase thrombolysis and review the current literature on the use of thrombolytic agents for the treatment of acute renal allograft vein thrombosis.

We report our experience with 73 patients who were initially selected for nonoperative management of an abdominal aortic aneurysm less than 5 cm in diameter. Size of the aneurysm was determined by ultrasound (34); arterlography (16); computerized tomography (17); plain x-ray (4); and magnetic resonance imaging (2). End points of the study were subsequent elective resection, rupture, death from cause other than rupture, or an intact aneurysm followed for a minimum of three years. Overall, 28 (38%) aneurysms were subsequently resected on an elective basis; four (5%) ruptured; 15 (21%) were intact at the time of the patient's death; and 26 (36%) remained intact during follow-up of 3 to 6.5 years. Indications for elective resection were aneurysm enlargement (21); symptoms suggesting impending rupture (3); and improvement in medical condition (4). In the 43 aneurysms initially less than 4 cm diameter, 16 (37%) had elective resection and one (2%) ruptured, and in the 30 that were 4–4.9 cm, 12 (40%) were resected and three (10%) ruptured. The four aneurysms that ruptured had enlarged to greater than 5 cm prior to rupture. We conclude that aneurysms less than 4 cm can be safely followed. Aneurysms 4–4.9 cm should be considered for operation, depending upon the size of the aneurysm, patient's life expectancy, and risk factors for surgery. Any aneurysm that enlarges should be resected, especially if the aneurysm becomes larger than 5 cm in diameter.

• Our experience with angioscopy suggests that direct visualization of the arterial lumen during thromboembolectomy procedures would provide a more reliable method of assessing luminal morphologic characteristics than angiography alone. We inspected 32 grafts (seven aortobifemoral, 18 infrainguinal bypass, and seven dialysis access fistula grafts) in 32 patients. Thirty-one patients had thrombotic events and one patient had an acute embolus. Angioscopy following standard catheter thrombectomy revealed significant amounts of retained thrombus or neointima in all thrombectomies. Angioscopic information from 18 patients with an infrainguinal bypass graft led to graft revision in six cases and placement of a new graft in 10 cases. One graft limb was replaced in seven aortobifemoral grafts, and multiple repeated thrombectomies were employed to extract debris in the remaining six cases. Repeated graft thrombectomy was also beneficial in dialysis access fistulas. Angioscopy allowed us to omit the completion angiogram and led to an improved technical result. We conclude that angioscopy is useful during thromboembolectomy procedures. (Arch Surg.1990;125:1357-1362)

We reviewed the records of 291 asymptomatic patients who underwent 377 carotid endarterectomy operations. The study excludes endarterectomies performed simultaneously with other operations that influence morbidity as well as endarterectomies on patients with symptoms caused by contralateral carotid stenosis. Postoperatively, nine patients had a stroke but two of the nine recovered completely after reoperation. Seven patients (2% of operations) were discharged with a neurologic deficit. One patient died of a myocardial infarction. Combined strokes with residual deficit and deaths totaled eight patients (2.2% of operations). During the time of the study the indication for operation changed from greater than 60% stenosis of the carotid artery to greater than 80% stenosis. This paper argues that, based on information currently available, a surgical morbidity rate of less than 3% justifies prophylactic endarterectomy. Surgeons must audit their results to demonstrate they can perform the operation with low risk to the patient.

Anastomotic false aneurysm (AFA) of the aorta or iliac artery is a potentially lethal complication of prosthetic grafts. To study this complication, the records of 18 patients with 22 noninfected AFAs (15 aortic and seven iliac) were reviewed. Patients with an intact AFA had a pulsatile abdominal mass, abdominal pain, an occluded graft, peripheral emboli, or a femoral anastomotic false aneurysm. All patients with a ruptured AFA were in shock, but 67% (four of six) had symptoms before hemorrhage. For diagnosis, single-plane angiography was 69% accurate (11 of 16), computed tomography was 100% accurate (six of six), and ultrasound was used once and suggested an AFA. Three patients with an AFA less than 5 cm diameter were initially observed; however, all three aneurysms rapidly enlarged and one ruptured. The operative mortality rate was 8% (1 of 12) for patients with an intact aneurysm and 67% (four of six) for patients with a ruptured aneurysm. Treatment was resection of the AFA and replacement with a new graft. Retroperitoneal AFAs often appear years after the initial operation, and life-long follow-up is required for patients with an aortic or iliac graft. All retroperitoneal AFAs should be resected since the outcome of patients with a ruptured AFA is poor. (J VASC SURG 1988;8:268-73.)

The records of 52 octogenarians who underwent resection of an abdominal aortic aneurysm were reviewed. Thirty-five elective operations were performed with an operative mortality of 8.6 percent, which was twice that of the group less than 80 years of age. Seventeen emergency operations were performed for rupture with an operative mortality of 58.8 percent. Postoperative follow-up in the elective group found that by 6 months 93 percent of surviving patients had returned to their preoperative status. Survival rates by life table analysis were 67 percent at 1 year, 52 percent at 3 years, and 14 percent at 5 years. In the ruptured group, all patients at risk were alive at 1, 3, and 5 years. We advise elective resection of an abdominal aortic aneurysm in the octogenarian with good functional capacity using the same criteria that: we use for younger patients. Most octogenarians can anticipate a prompt return to their usual environment and a meaningful postoperative life-style.

Near-total or total blindness caused by chronic ocular ischemia is a well-recognized complication of severe atherosclerotic occlusive disease of the carotid artery (CA) but has not been previously reported in the English-language literature as a sequela of an occlusive CA injury. This report describes a patient who sustained a gunshot wound to the neck, which injured the ipsilateral internal CA, external CA, and vertebral artery. The location of the injuries precluded arterial repair. The patient was neurologically intact after operative exploration. Twenty months after the injury a marked loss of vision in the ipsilateral eye was detected. Chronic ocular ischemia was diagnosed from clinical findings and ophthalmoscopic examination results. Knowledge that chronic ocular ischemia and blindness can occur after an occlusive CA injury supports the use of primary arterial repair for all CA injuries. In those instances in which repair is not technically possible, frequent ophthalmoscopic examinations and testing of visual acuity should be used postoperatively to diagnose ocular ischemia; thus treatment to prevent the loss of sight can be carried out.

Color flow duplex scanning was used to "map" the iliofemoral and femoral popliteal segments in 61 patients (84 extremities) undergoing evaluation for excimer laser angioplasty. Eight locations, iliac, common femoral, profunda femoris, proximal and distal superficial femoral artery, proximal and distal popliteal, and tibioperoneal trunk were scored as normal versus abnormal, greater than 50% stenosis, or occluded, and occlusions were measured in centimeters. Specificity, sensitivity, and accuracy were calculated with the arteriogram as the gold standard (83% and 96%, respectively, for normal vs abnormal, 87% and 99% for 50% stenosis, and 81% and 99% for occlusions). Color flow accurately identified the presence and extent of occlusions in 48 of 51 extremities (94%) when compared to arteriography plus operative findings, since arteriography alone tended to overestimate occlusion length. It is concluded that color flow Doppler alone may be used to screen patients with peripheral vascular disease to assess candidacy for endovascular procedures without antecedent arteriography, and that arteriography alone would exclude some patients from consideration by falsely overestimating occlusion lengths.

Purpose: This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis. Methods: The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined. Results: Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD. Conclusions: Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD. (J Vasc Surg 1996;24:597-607.)

The 3.4 percent rate of symptomatic recurrent carotid stenosis after carotid endarterectomy confirms previous reports [7]. Most of the recurrent stenoses occurred in women, and it is postulated that small arteries have less tolerance for myointimal proliferation seen after endarterectomy and that primary patch angioplasty should be considered when the internal carotid artery is less than 3 mm in diameter. When recurrent stenosis of the nonarteriosclerotic type is encountered, patch angioplasty without endarterectomy is the procedure of choice.

Major postoperative stroke after carotid endarterectomy is often due to carotid thrombosis, and prompt thrombectomy can reverse the neurologic deficit. We advise reoperation providing the stroke occurs within several hours of carotid endarterectomy, preferably when the patient is in the recovery room, and reoperation can be done immediately. We do not delay reoperation for angiography. Reoperation has not been beneficial for strokes that occur later in the patient's course or when there has been a severe preoperative neurologic deficit. Patients with a mild postoperative stroke, especially if the stroke represents worsening of a preoperative deficit, will often improve without intervention.

• Patients undergoing hemodialysis, whose radial-cephalic arteriovenous fistulas (RCAVFs) were unsatisfactory because of poor accessibility, were treated by surgical repositioning of the full length of arterialized cephalic vein in the forearm. Marked improvement in accessibility for more than one year was achieved in 15 of 18 delayed venous repositioning operations. This procedure is recommended for improving certain types of inadequate RCAVF. ( Arch Surg 111:675-677, 1976)

Cardiac decompensation is clearly the major complication of aortic reconstructive surgery that leads to morbidity. Major changes in intravascular volume, third spacing, and increased systemic vascular resistance are extremely stressful to the diseased heart. Hemodynamic monitoring is readily available to provide an accurate evaluation of myocardial sensitivity and to allow for appropriate pharmacologic manipulation to preclude cardiac catastrophe. We believe all patients undergoing abdominal aortic reconstructive surgery should receive the benefit of pulmonary artery catheterization and intraarterial monitoring. The only requirement is a staff of surgeons, anesthesiologists, and nurses capable of correct interpretation of the data and use of drug therapy based on this information. The benefits are an accurate assessment of cardiac function with the ability to modulate the patient's hemodynamic values, preventing volume shifts, hypertensive and hypotensive crises, and abnormal fluctuations in preload and afterload, and ultimately a safer perioperative course.

Pathology, Clinical manifestations, and diagnostic aids such as abdominal paracentesis, angiography, and radionuclide studies, and important features of emergency splenectomy.

Forty-three patients with aortoiliac arteriosclerosis were preoperatively assigned in random fashion, to a thromboendarterectomy (TEA) or a bypass graft (BPG) group without regard to the historical data, the preoperative aortograms, or the preoperative physical findings. Of 21 patients in the BPG group, the immediate success rate was 100% and all the patients left the hospital alive, though one died of an aortic suture line disruption six weeks postoperatively. Of 22 patients assigned to the TEA group, six required some form of BPG due to inability to complete TEA on one or both sides, an intraoperative failure rate of 27%. One patient in this group died postoperatively of renal failure. Aortoiliofemoral TEA and BPG are not comparable procedures. Anatomic factors and technical skill must be considered in choosing the proper operation.

The accepted treatment for post-traumatic arteriovenous fistulas has been to permit development of collateral circulation and then perform either vascular repair, excision of the fistula, or quadruple ligation. At the Los Angeles County-University of Southern California Medical Center, a policy of early surgical repair was developed about nine years ago. Twenty-seven patients with fistulas involving major arteries of the upper and lower extremities, neck, and branches of the aortic arch have been treated. Thirteen patients were operated upon within 24 hours of injury, seven patients between one and four days, and seven patients between 11 and 26 days. The results were excellent in 23 patients, good in two, poor in one, and one patient died. Early surgical repair of acute post-traumatic arteriovenous fistulas is recommended.