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Popliteal vein aneurysm (PVAs), though uncommon, can be a cause of pulmonary emboli. They can also result in pulmonary vein embolism despite the use of anticoagulation therapy.We report the case of an otherwise fit, 64-year-old male who had a history of sudden onset of dyspnea on exercise with near syncope.A computed tomography pulmonary angiogram confirmed filling defects in the lung bases in keeping with pulmonary emboli. He was anticoagulated and a venous duplex scan revealed a fusiform suprageniculate PVA with no evidence of thrombus in the lumen. He underwent resection of the aneurysm with lateral vein patch graft repair and was placed on anticoagulation for 6 months with no recurrence after 2 years of follow-up.PVAs are rare and can either be symptomatic or asymptomatic. We advise early surgical treatment to prevent the significant morbidity and mortality associated with thromboembolization.Written consent was obtained from the patient for publication of case and use of images.

Randomized controlled trials (RCTs) have been the core of level 1 data in medical and surgical science for at least the last three decades. However, frequently patient selection is very narrow, anatomic criteria do not match real-world experience, and much of the work is done in selected academic centers. We use RCTs to help explain the rational for intervention and then rely on longitudinal registries and single center data to give the patients a real-world expectation concerning outcomes and complications in our hands.Randomisierte kontrollierte Studien (RCTs) bildeten mindestens drei Jahrzehnte lang die Basis für Daten der Evidenzklasse 1 in den Wissenschaftsbereichen Medizin und Chirurgie. Jedoch ist die Patientenselektion häufig sehr begrenzt, die anatomischen Kriterien entsprechen nicht den realen Erfahrungen und die Hauptarbeit wird in ausgewählten akademischen Zentren geleistet. Auf diese Weise tragen RCTs auch zu den Schwierigkeiten der Daten aus früheren Beobachtungsstudien bei. Wir verwenden RCTs, um die Begründung für einen Eingriff zu erklären, und vertrauen dann auf Längsschnittregister- und Single-Center-Daten, um den Patienten realistische Erwartungen bezüglich den Ergebnissen und Komplikationen in unseren Händen zu geben.

Background This study evaluated the safety and haemostatic effectiveness of a fibrin sealant (EVICEL™ Fibrin Sealant (Human)) during vascular surgery. Methods This prospective randomized controlled trial compared the haemostatic effectiveness of fibrin sealant (75 patients) or manual compression (72) in polytetrafluoroethylene (PTFE) arterial anastomoses. The primary endpoint was the absence of bleeding at the anastomosis at 4 min after randomization. Secondary endpoints included haemostasis at 7 and 10 min, treatment failures and the incidence of complications potentially related to bleeding. Adverse events were recorded. Results A higher percentage of patients who received fibrin sealant versus manual compression achieved haemostasis at 4 min (85 versus 39 per cent respectively; odds ratio 11·34, 95 per cent confidence interval 4·67 to 27·52; P < 0·001). Similarly, a higher percentage of patients who received fibrin sealant achieved haemostasis at 7 and 10 min (both P < 0·001). The incidence of treatment failure was lower in the fibrin sealant group (P < 0·001). The rate of complications potentially related to bleeding was similar (P = 0·426). Some 64 per cent of patients who received fibrin sealant experienced at least one adverse event, compared with 71 per cent who received manual compression. Conclusion This fibrin sealant was safe, and significantly shortened the time to haemostasis in vascular procedures using PTFE. Registration number: NCT00154141 (http://www.clinicaltrials.gov).

Treatment of carotid bifurcation disease in patients presenting with acute stroke has been a controversial issue over the past four decades. Classically, patients were asked to wait four to six weeks before intervention was entertained in order for the brain to stabilize and the risks of intervention to be minimized. Unfortunately, up to 20% of patients will have a secondary event after their index event and the window of opportunity to save, potentially salvageable ischemic tissue will be missed. Early reports had demonstrated poor results with intervention. However, more recently, institutions such as ours have demonstrated excellent result in early intervention in patients who present with stable mild to moderate stroke with an NIH stroke scale less than 15 and preferably less than 10, present with stroke and ipsilateral carotid artery lesion of 50% or greater. Also more recently, we have been aggressively treating patients with larger ulcerative plaques even if the stenosis approaches 50%. In our and others experiences, patients who are treated at institutions that have comprehensive stroke centers (CSCs) where they have a multidisciplinary system that consists of vascular surgeons, neuro interventionalists, stroke neurologists, specifically trained stroke nursing staff and a neuro intensive ICU have had optimal results. Early assessment, diagnosis of stroke with recognition of cause of embolization is mandatory but patient selection is extremely important; finding those patients who will benefit the most from urgent intervention. Most studies have demonstrated the benefit of carotid endarterectomy in these patients. More recent studies have demonstrated acceptable results with carotid stenting, especially in smaller lesions, those less than 1.2 centimeters. Early intervention should be avoided in most patients who are obtunded or with an NIH stroke scale greater than 15 or who do not have any "brain at risk" to salvage. These patients may be better served by being treated medically than those small group of patients that do have some improvement may benefit from interval intervention.

SUMMARY BACKGROUND DATA: The outcome of standard longitudinal carotid endarterectomy (CEA) can be measured by preservation of neurologic function with a low incidence of restenosis. Closure of the internal carotid arteriotomy with or without a patch may predispose to restenosis. Alternatively, transection of the internal carotid artery at the bulb with eversion endarterectomy allows expeditious removal of the plaque and direct visualization of the endpoint. Because the proximal internal carotid artery is anastomosed to the common carotid artery, this obviates the need for patch closure. The authors report their results with this technique in more than 2200 procedures. METHODS: From May 1993 to March 1998, 1855 patients underwent 2249 CEAs using the eversion technique. During the same period, 410 patients had 474 CEAs by standard technique. Three hundred fifteen procedures in the eversion group and 65 procedures in the standard group were combined CEA and coronary artery bypass grafts. Most solo CEAs (97%) were performed in awake patients using regional anesthesia. Shunts were used on demand in 6% of CEAs. RESULTS: The operative mortality rate was 1.02% (16/1575) in the solo eversion group and 2.2% (9/410) in the standard group. There were 18 permanent neurologic deficits (0.8%) in the eversion group and 11 (2.3%) in the standard group. Transient neurologic deficits occurred in 20 patients (0.9%) in the eversion group and 13 patients (2.7%) in the standard group. Of the 1855 patients, 1786 (96%) presented for duplex ultrasound follow-up. There were seven (0.3%) stenoses greater than 60% in the eversion group versus five (1.1%) in the standard group. CONCLUSIONS: Eversion CEA can be performed safely with a low rate of stroke and death and a minimal restenosis rate in short- and long-term follow-up.

Adaptation of new clinical products should be based upon thorough scientific evaluation of properties and performance in vitro and in vivo. Developmental animal research experimentation is classically carried out by the manufacturer with eventual government approval. However, objective data needs to be recorded during clinical trials including handling characteristics, bleeding, tensile strength, kinking, seamline break, dilatation, anastomotic deterioration, patency, and incorporation. Since April 1991, 1010 stretch polytetrafluoroethylene (PTFE) aortic grafts have been implanted at our institution and data were recorded prospectively. Six hundred and seven were for elective abdominal aortic aneurysms, 46 for symptomatic abdominal aortic aneurysms, 58 for ruptured abdominal aortic aneurysms, 17 for elective thoracoabdominal aneurysms, 3 for ruptured thoracoabdominal aneurysms and the remainder were for various aortoiliac pathology. Average age of the patients was 69 (range: 10-95), 66% were males, 25% were diabetics. Overall operative mortality was 5.8% (2.9% in elective cases and 26.6% in emergent cases). There were 23 occlusions; 21 were revised and 2 were replaced with axillofemoral bypasses. Estimated blood loss was 784 cc in elective cases and 1918 cc in emergent cases. Grafts were followed by duplex ultrasound or CT scan every 3 months during the first year and every 6 months thereafter. There were no graft dilatations or false aneurysms in this series. There was one graft infection and no perigraft seromas or anastomotic deteriorations during this follow up. Follow up was complete in 94% of these patients. In conclusion, stretch PTFE graft has acceptable handling characteristics, no excessive bleeding at the suture line and had no anastomotic or graft dilatation. This graft material was suitable for thoracic, visceral, renal and abdominal aortic reconstructions.

The foot comprises 3 compartments bounded by bone and fascia, each compartment containing muscle and vascular and nervous structures. Infection leading to an increase in pressures in the compartments results in rapid necrosis, a pathologic process characteristic of diabetic feet. Treatment involves fasciotomy and complete debridement of devitalized tissue with possible amputation of the involved digits. Knowledge of the anatomic structure of the foot and its compartments is therefore essential in effectively managing the diabetic foot.

Management of infected ischemic diabetic limbs requires antibiotic therapy, abscess drainage, and revascularization. However, revascularization is often delayed for several days or weeks as the infection is controlled. In an effort to decrease hospital stay and costs and to increase limb salvage, a series of 974 extremities with distal occlusive disease were managed with autogenous distal bypass. Some 136 of these limbs (125 diabetic) had severe invasive infections. These patients received intravenous antibiotics in all cases and abscess drainage if necessary. Vascular reconstruction was carried out as soon as possible, within 48 h of admission. An in situ bypass was used preferentially (107 cases). Patients were maintained on intravenous antibiotics in the perioperative period. Partial foot amputations, when necessary, were performed in 111 cases, usually 3–5 days after vascular reconstruction. There were no graft infections or major wound infections. There were two cases of skin edge necrosis requiring reoperation due to flap mobilization and consequent ischemia. Urgent revascularization with an autogenous conduit may be carried out in patients with invasive foot infections expeditiously, with high rates of limb salvage. Graft and wound infections are not common in this setting. Costly prolonged pre-bypass hospitalization in these cases is unnecessary. Copyright © 1996 The International Society for Cardiovascular Surgery.

The efficacy of carotid endarterectomy for the prevention of strokes has been well demonstrated in recent multicenter randomized trials. However, patients presenting with bilateral significant disease pose a difficult problem to the vascular surgeon. Currently, bilateral carotid endarterectomies are staged at varying intervals between operations, with surgeon and patient weighing the risks of waiting for surgery versus the risks of having both procedures done within a shortened interval. There are few data and no consensus on the optimal time interval between these operations. In order to evaluate the timing of carotid endarterectomies in patients with severe bilateral disease, the authors reviewed their experience with patients who had bilateral procedures performed during one hospitalization. Over the past 5 years, they have performed 204 such carotid endarterectomies in 102 patients. Cervical block anesthesia was used in 99% (201/204) of these procedures. All patients either had symptomatic disease, > 60% stenosis or severe ulcerative plaque as defined by duplex scan and/or preoperative angiography. Symptomatic stenoses were the operative indications in 39% (80/204) of the patients; the remaining 61% (124/204) were symptom-free. The majority of patients (80%; 164/204) had their second procedure performed within 2 days of their first operation. There was no operative mortality and only one permanent neurologic defect in this group for a combined stroke mortality rate of 1%. Three patients (1.5%) had transient neurologic deficits postoperatively which completely resolved by discharge. These data show that bilateral carotid endarterectomies can be performed safely and effectively during one hospital admission with a short interprocedural interval and without an increase in mortality or morbidity.

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (

Acute ischemia-reperfusion of extremities is characterized by edema, compartment syndrome and neuromuscular dysfunction. Intravenous hypertonic mannitol has been shown to be of benefit in several experimental models. The authors' 5-year experience with the use of hypertonic mannitol and the treatment of acute ischemia reperfusion injuries in humans has been reviewed. Some of 186 patients with acute arterial occlusion following thromboembolism (149) and trauma (37) were treated. Hypertonic mannitol (25 g intravenous bolus followed by 5-10 g intravenous/h) was given perioperatively. Length of preoperative ischemia varied from 1 to 24h. Some of 57.5% of patients had preoperative neuromuscular dysfunction. Following revascularization, limb salvage was obtained in 97.7% of surviving patients and neuromuscular dysfunction improved in 89%. Overall, 15% required fasciotomy. The mortality rate was 3.2%. These data suggest that hypertonic mannitol may have some protective effect in acute ischemia-reperfusion injuries of human extremities. It may decrease the need for fasciotomy and minimize neuromuscular dysfunction.

Purpose: The purpose of this study was to determine the safety and efficacy of performing carotid endarterectomy procedures with the patient receiving cervical block anesthetic. Methods: Over the last 14 years, 654 carotid endarterectomy procedures were performed with patients receiving regional anesthetic. Intraluminal shunts were placed on demand, if neurologic changes with clamping of the carotid artery developed in the patient. During the same period, 419 cases were done with the patients receiving general anesthetic. Choice of anesthetic was based on surgeon and patient preference. Results: In the regional anesthetic group the indications for operation included transient ischemic attack (311), asymptomatic hemodynamically significant stenosis (146), amaurosis fugax (106), stroke (86), restenosis (3), and aneurysm (2). Shunts were used in 46 of 654 cases (7%). Conversion from regional to general anesthetic was required in seven patients (1.1%). The operative mortality rate was 0.76% (5 of 654). Permanent nonfatal neurologic deficits occurred in 0.76% (5 of 654), and temporary neurologic deficits occurred in 1.07% (7 of 654). Conclusions: On the basis of these results, we believe regional cervical block anesthetic is an acceptable option to the routine use of shunts performed with the patient receiving general anesthetic during carotid endarterectomy. In addition, the ability to continuously assess the awake patient receiving cervical block may contribute to a decrease in perioperative stroke and mortality rates while simplifying functional cerebral monitoring during carotid endarterectomy. (J VASC SURG 1994;19:1015–20.)

The most frequently used conduit for infrainguinal or coronary artery bypass is the saphenous vein, and this report describes the ultrasonic evaluation of anatomic variations in over 1400 limbs. The thigh portion of the greater saphenous vein consisted of a single venous conduit in 67% of the limbs, a complete double system in 8%, a branching double system in 18% and a closed loop double system in 7%. In 92% of the cases, the vein was in medial position, with the remaining 8% positioned laterally. In the calf, a single vein was observed in 65% of the limbs with the remainder demonstrating a double venous system. The vein was positioned anteriorly in 85% of the limbs. The remaining 15% were positioned posteriorly, with 7% of these being a single dominant vein. Proper knowledge of saphenous vein anatomy is vital to the surgeon preparing to use this vein as a bypass conduit and can aid in its preoperative assessment.

To the Editor: Chaturvedi et al.1 report on neurologist follow-up in 44 patients with carotid endarterectomy (CE) over a 4-year period. Of these, 70.5% were referred for symptomatic stenosis and 29.5% were asymptomatic. Their 30-day mortality rate was 4.5% and 30-day stroke and death rate was 11.4%. We find these complication rates alarmingly high. The authors conclude, based on limited data, that “unless neurologists are consistently involved in the preoperative and postoperative evaluation of patients who undergo CE, the complication rate of this procedure is likely to be underestimated.” We found no difference in complication rates reported by either vascular surgeons or neurologists at our center. Our vascular surgeons performed 650 CE last year with combined stroke/mortality risk of 2.2% in symptomatic and 1.9% in asymptomatic patients.2 In 1990, when only 66 CE were done, the combined stroke/mortality rate was 4.75%,2 still below that reported by the authors. Perioperative complications reported by Chaturvedi et al.1 were in high-risk patients biased toward worse outcome. Combination coronary bypass grafting with CE has perioperative stroke rates of 2 to 20%.3 Occluded contralateral carotid artery increases ipsilateral stroke risk twofold with CE.4 The benefit of CE in patients with symptomatic or asymptomatic carotid stenosis is based on performing surgeons having combined morbidity and mortality rates of

Purpose With the FDA approval of thoracic endografts, extra-anatomic reconstruction of the aortic arch has allowed for more suitable proximal landing zones and increased applicability of thoracic endovascular procedures. We evaluated our short term and long term results of extra-anatomic reconstruction of the carotid and subclavian vessels. Methods One hundred and forty three (143) procedures were performed for extra-anatomic carotid and subclavian reconstruction. Of these 143 operations: 85 were carotid subclavian reconstructions, 22 were carotid crossover bypasses, 30 were subclavian carotid reconstructions and 6 were carotid subclavian transpositions. Sixty (42%) were male, 20 (14%) were diabetic, and 63 (44%) were current smokers. Mean age was 63 (SD +/− 12.3). Indication for surgery was primarily for occlusive or embolic disease (97%). In those patients undergoing bypass graft, prosthetic (ePTFE) was used in 93%. Follow-up was performed at 3 and 6 month intervals by ultrasound and pulse volume recordings where indicated. Life table analyses were used to analyze patency. Results Of the 143 reconstructions operative mortality was 1 (0.7%). Non-fatal complications included 3 (2.1%) for bleeding, 1 (0.7%) wound infection, 2 (1.4%) TIA, 1 (0.7%) suffered a non-fatal stroke, 2 (1.4%) had postoperative myocardial infarctions, and 6 (4.3%) late (>30-day) occlusions. Follow-up was 1 to 124 months (mean: 39 months). Primary patency at 1 year was 98%, 3 years 96%, and 5 years was 92%. Conclusion Extra-anatomic arch reconstruction can be performed safely and appears to be durable over long term follow-up. Its use with endovascular grafting should provide a durable reconstruction for patients who require aortic “debranching” prior endovascular thoracic aortic aneurysm repair.

One ofthe perceived limitations of the left retroperitoneal approach to the aorta is inadequate access to the right renal artery. Many consider the need for a concomitant right renal artery revascularization a contraindication to performing an aortic reconstruction through the left retroperitoneum. Exposure of the right renal artery can be difficult due to the posterior course of the artery behind the vena cava. However, when the aorta is transected, the right renal artery can be easily approached with anterior and cephalad displacement of the aortic root. Over the past 3 years, 52 patients have had right or bilateral renal artery revascularization via the left retroperitoneal approach; of these procedures, 37 were performed with concomitant aortic procedures. In total, 34 patients had bilateral and 18 had unilateral revascularizations. Five patients had a transaortic endarterectomy performed, and 36 were bypassed with 6-mm expanded polytetrafluoroethylene side limbs from the aortic graft. Indications for revascularization were: 39 for suprarenal aortic bypass, seven for renal salvage and six for primary renovascular hypertension. All reconstructions have remained patent and all have been followed by serial duplex and renal flow scans (follow-up for 1-42 months). The operative mortality rate was 5.8% ( 3 52 ). There were no major cardiorespiratory complications in this group. Adequate exposure to the proximal right renal artery can be obtained through the left retroperitoneal approach to the aorta, and successful revascularization of one of both renal arteries can be technically performed with acceptable mortality and morbidity. Copyright © 1996 The International Society for Cardiovascular Surgery.

Technological advancements have lead to dramatic improvements in stentgraft device design resulting in more trackable delivery systems and transrenal uncovered stents and barbs for better fixation. Transrenal bare-stents may limit stentgraft migration, particularly in patients with short or flared proximal aortic necks. However, potential disadvantages might be in worsening renal function, particularly in patients with preexisting renal insufficiency. We retrospectively analyzed our recent 7 year experience of patients undergoing endovascular aneurysm repair (EVAR) using a variety of stentgrafts with and without transrenal bare-stent fixation. Patients were divided into 2 groups; infrarenal fixation (IRF) vs transrenal fixation (TRF), or patients with preoperative serum Cr values that were normal (= or1.5 mg/dl) vs slightly elevated (1.6-2 mg/dl), vs markedly elevated (2.1- 3.5 mg/dl). The exclusion criteria included patients with chronic renal insufficiency (CRI) on hemodialysis, and preoperative high-grade renal artery stenoses requiring angioplasty and stenting. Of 705 patients that underwent EVAR, 496 (IRF: 385 [78%], and TRF: 111 [22%]) were available with routine evaluations of serum Cr and CT scans. Preexisting comorbidities, mean procedure contrast volume, and postprocedure follow-up were similar in both groups. In the immediate postoperative period, mean serum Cr did not change significantly in either the IRF group (1.3+/-0.7 mg/dl to 1.2+/-0.9 mg/dl) or the TRF group (1.3+/-0.5 mg/dl to 1.3+/-0.6 mg/dl). Mean serum Cr did, however, significantly increase over longer follow-up in both groups: 1.4+/-0.8 mg/dl for IRF (P0.03), and 1.5 +/- 0.8 mg/dl for TRF (P0.01). Cr clearance was similarly unchanged in the immediate postoperative period (58+/-23 to 61+/-25 ml/min/1.73 m2 for IRF group, 53+/-17 to 55+/-17 ml/min/1.73 m2 for TRF group), but was significantly decreased in longer follow-up (53+/-23 ml/min/1.73 m2 for IRF, p0.02: and 48+/-16 ml/min/1.73 m2 for TRF, P0.01). There were no significant differences in serum Cr increase (p=0.19) or Cr clearance decrease (p=0.68) between the IRF and TRF groups. Small renal infarcts were noted in 6 patients (1.6%) in the IRF group, and in 8 patients (7%) in the TRF group (p=0.37). Of patients with normal preoperative renal function, renal dysfunction developed in 7.7% of IRF group and 6.1% of TRF group (p=0.76). In patients with preexisting CRI, renal dysfunction developed in 18.2% of IRF group, and 17.1% of TRF group (p=0.95). Eight patients with postoperative renal dysfunction, 5 (1.3%) from IRF group and 3 (2.7%) from TRF group subsequently required hemodialysis, and this difference was not statistically significant (p=0.91). We also analyzed 200 consecutive patients undergoing EVAR with intra-arterial contrast agents with and without preexisting CRI not on dialysis. The groups were identified on the basis of preprocedure serum Cr: group 1 (n=108), Cr less than 1.5 mg/dL (normal range); group 2 (n=65), Cr 1.5 to 2.0 mg/dL; group 3 (n=27), Cr 2.1 to 3.5 mg/dL. Routine precautions in patients with CRI included preoperative intravenous hydration with 2 L of normal saline solution, discontinuation of all nephrotoxic drugs, intraoperative administration of mannitol (0.5 g/kg intravenously), and use of nonionic, low osmolar intra-arterial contrast agent (Omnipaque 350). One-hundred and eight patients had normal renal function (group 1), and 92 patients had preexisting CRI with baseline Cr 1.5 to 2.0 mg/dL (group 2, n=65) or 2.1 to 3.5 mg/dL (group 3, n=27). Comorbid conditions included coronary artery disease (group 1, 51%; group 2, 49%; group 3, 59%), hypertension (group 1, 39%; group 2, 46%; group 3, 52%), and diabetes mellitus (group 1, 25%; group 2, 35%; group 3, 48%). In groups 1, 2, and 3, the mean volume of low osmolar contrast agent used was 210 cc, 160 cc, 130 cc, respectively; hemodynamic instability developed in 3, 1, and 1 patient, respectively. The incidence of postoperative complications between the 3 study groups was not statistically different. In grications between the 3 study groups was not statistically different. In group 1 a transient increase in serum Cr (30% over baseline and1.4 mg/dL) was noted in 3 patients (2.7%), 2 of whom (1.9%) required temporary hemodialysis and 1 (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in 2 patients (3.1%); both patients (3.1%) required temporary hemodialysis, and 1 patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in 2 patients (7.4%); 1 patient (3.7%) required temporary hemodialysis, and 1 patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (p0.05), and larger contrast volume was associated with an increase in serum Cr (p0.05) during the postoperative period. Following EVAR renal function declines slightly with both IRF and TRF. Our data show no overall difference between patients with IRF and TRF with respect to infarcts, decline in renal function, or onset of dialysis. There were a slightly greater number of renal infarcts in the TRF group, but these infarcts were clinically inconsequential. In patients with CRI, EVAR with intra-arterial radiographic contrast agents is believed to impair renal function, and CRI is considered a relative contraindication to the procedure. Results of our investigation indicate that risk for worsening renal insufficiency, dialysis, and death is only slightly and not significantly greater in patients with CRI compared with patients with normal renal function. With appropriate precautions of avoiding perioperative hypotension and limiting the volume of nonionic contrast agents, CRI need not be a contraindication for EVAR with intra-arterial contrast agents.

background : Patients undergoing the placement of coronary artery bypass grafts (CABG) with hemodynamically significant carotid artery lesions pose a difficult problem for both cardiac and vascular surgeons. Despite numerous studies, there has been no consensus of opinion as to the proper management of these patients. In numerous series, the combined mortality and perioperative stroke rates in concomitant carotid endarterectomy and CABG procedures have ranged from 8% to 40%. This has made many surgeons consider staging these procedures. methods : Retrospective analysis of patients undergoing combined carotid endarterectomies and CABG from 1980 to 1993 were reviewed. Two hundred six procedures were performed in 189 patients. Seventeen patients had bilateral carotid endarterectomy performed with CABG. The average age of our patient population was 66 years, with 123 being male and 66 being female. Seventy-five percent of the patients were asymptomatic with the remainder having transient ischemic attacks, amaurosis fugax, or prior stroke. results : Operative mortality was 2%, with three of four patients dying of cardiac failure and one of a stroke. A temporary neurologic deficit was seen in 2% of patients, and a permanent neurologic deficit was seen in 2 of 206, or 1%. Thirty shunts were used in this series, mostly in patients with contralateral carotid occlusion. All procedures were performed under general anesthesia with full invasive monitoring. One patient was re-explored for bleeding, and one patient had a temporary hypoglossal palsy. A total of 203 cases had the arteriotomies closed primarily, and 3 required patches. conclusion : In our experience, simultaneous carotid endarterectomy and CABG can be performed with an acceptable mortality and morbidity and does not appear to put the patient at an increased risk. Staging of these procedures may not be necessary in most cases.

Blunt trauma to the upper extremity may cause extensive vascular damage in addition to severe musculoskeletal injury. Over a 5.5-year period. 17 patients with a total of 23 arterial injuries were treated. Diagnosis was made in 16 patients before surgery by physical and Doppler ultrasonographic examination. Angiography performed in ten patients assessed the extent of injury. Associated orthopedic injuries were present in 11 patients and neurologic injury in 16. At surgery, 21 of 23 arterial repairs required autologous vein. The initial limb salvage rate was 76%. Pour patients underwent above-elbow amputation because of progressive sepsis and myonecrosis. A fifth underwent delayed amputation at 7 months due to loss of limb function. Neurologic impairment was the major long-term morbidity. The data show that outcome following blunt vascular trauma of the upper extremity is governed by the associated injuries.

Carotid endarterectomy by the eversion technique allows for all of the benefits of conventional endarterectomy but obviates the need for a distal suture line on the smaller internal carotid artery, and thus batching. Carotid artery reanastomosis onto the bifurcation can be quickly and simply performed with almost no risk of closure-related restenosis, given the anastomosis is on the larger of 2 arteries. In our experience of over 3,000 eversion carotid artery endarterectomies, the restenosis rate has been less than 1% judged by rigorous duplex follow-up. In this article, the technique and utility of eversion carotid endarterectomy is discussed.

Objective To evaluate the short- and long-term results of surgical reconstruction of the renal arteries, the authors review their experience with more than 600 reconstructions performed over a 12-year period. Background Data Reconstruction of the renal arteries, whether for primary renal indications or concomitantly with aortic reconstruction, has evolved over the past 40 years. There is concern that renal artery reconstructions carry significant rates of mortality and morbidity and may fare poorly compared with less-invasive procedures. Methods From 1986 to 1998, 687 renal artery reconstructions were performed in 568 patients. Of these, 105 patients had simultaneous bilateral renal artery reconstructions. Fifty-six percent of the patients were male; 11% had diabetes; 35% admitted to smoking at the time of surgery. Mean age was 67 (range, 1 to 92). One hundred fifty-six (23%) were primary procedures and the remainder were adjunctive procedures with aortic reconstructions; 406 were abdominal aortic aneurysms and 125 were aortoiliac occlusive disease. Five hundred procedures were bypasses, 108 were endarterectomies, 72 were reimplantation, and 7 were patch angioplasties. There were 31 surgical deaths (elective and emergent) in the entire group for a mortality rate of 5.5%. Predictors of increased risk of death were patients with aortoiliac occlusive disease and patients undergoing bilateral simultaneous renal artery revascularization. Cause of death was primarily cardiac. Other nonfatal complications included bleeding (nine patients) and wound infection (three patients). There were 9 immediate occlusions (1.3%) and 10 late occlusions (1.5%). Thirty-three patients (4.8%) had temporary worsening of their renal function after surgery. Conclusion Renal artery revascularization is a safe and durable procedure. It can be performed in selected patients for primary renovascular pathology. It can also be an adjunct to aortic reconstruction with acceptable mortality and morbidity rates.

Patients who present for coronary artery bypass grafting with hemodynamically significant carotid artery lesions pose a difficult problem for both the cardiac and vascular surgeons. There is no consensus as to the proper management of these patients despite numerous studies. Prospective collection of data was performed in patients undergoing combined carotid endarterectomy and coronary artery bypass grafting's from April 1980 to November 1996. A total of 470 simultaneous carotid endarterectomy's and coronary artery bypass grafting's were performed in 420 patients. The average age of the patient was 69 years, with 62% being male, 15% being diabetic and 38% being smokers. Sixty (13%) presented with Transient ischemic attacks, 22 (5%) presented with amaurosis fugax, 16 (3.4%) presented with a prior history of stroke and 372 (70%) were asymptomatic. Operative mortality was 2.4% or 10 patients; 90% of those patients died from cardiac complications postoperatively and one patient died of a stroke. Permanent neurological deficits occurred in five (1%) of the patients, and six (1.7%) of the patients had a transient neurological deficit that improved prior to discharge. In conclusion, in our experience simultaneous carotid endarterectomy with coronary artery bypass grafting can be performed with an acceptable mortality and morbidity and does not appear to put the patient at a higher risk than when either procedure is performed alone.

Arterial reconstructions performed for limb salvage have increasingly used peroneal and dorsalis pedis arteries as outflow vessels. However, there have been few published reports comparing the patency and limb salvage of these alternative outflow tracts. In this report, we have examined our experience with the peroneal and dorsalis pedis artery bypasses for limb salvage.During a 19-year period, more than 3,500 infrageniculate reconstructions were performed for limb salvage at our institution. Eight hundred and eighty were performed to the peroneal artery and 291 were performed to the dorsalis pedis. Patients' demographics were similar in both groups. Sixty-three percent of patients were male and 52% were diabetic. All surgeries were performed for patients with critical ischemia. In situ technique was used in 68% of peroneal reconstructions and 66% of dorsalis pedis bypasses, respectively. Translocated veins were used in 28% of bypasses and spliced veins were used in 32%.Secondary patency rates to the peroneal reconstructions were 89% and 76% at 1 and 5 years, and 88% and 68% for the dorsalis pedis bypasses, respectively. No statistical difference was found. Sixteen (1.8%) of peroneal artery reconstructions were hemodynamic failures and four (1.4%) were hemodynamic failures in the dorsalis pedis group. Wound complications were observed in 19 (2.2%) of the peroneal group and 7 (2.4%) of the dorsalis pedis group. Limb salvage rates for the peroneal artery are 96% and 93% at 1 and 5 years, respectively, and 95% and 87% for the dorsalis pedis reconstructions, respectively.This experience indicates that both peroneal and dorsalis pedis artery reconstructions have acceptable patency and limb salvage rates. Selection of one of these two outflow tracts, when a choice exists, may depend on the conduit limitation and the adjacent tissue infection. However, both outflow tracts are durable and hemodynamically effective for limb salvage.

Objective The objective of this article is to determine whether retroperitoneal approach for aortic surgery has certain physiologic, technical advantages. Summary Background Data The retroperitoneal approach for abdominal aortic reconstruction classically had been reserved for select patients with either high-risk comorbid disease or specific anatomic problems that preclude the transabdominal approach. With increasing appreciation of the physiologic, anatomic, and technical advantages of the extended posterolateral retroperitoneal approach, the authors have expanded its use for repair of all types of aortic visceral and renal artery disease as well as ruptured abdominal aortic aneurysm and infected aortic grafts. Methods From January 1981 to September 1995, 2340 retroperitoneal aortoiliac reconstructions were performed in 2243 patients. Aortic reconstructions accounted for 1756 cases : 1109 for elective abdominal aortic aneurysms, 210 for ruptured and symptomatic aortic aneurysms, 399 for occlusive disease, 18 for infected aortic grafts, and 20 for other indications. Iliofemoral disease was the indication for 584 procedures. As experience was gained, this approach also was used for 417 renal and 50 celiac and superior mesenteric artery reconstructions. Results The mean age was 67 years with 1590 men and 653 women. Overall mortality was 5.2% for all aortic cases : 2.4% for elective, 12.6% for symptomatic, and 29.0% for ruptured aortic aneurysms. Major complications occurred in 12.5% of the elective procedures and in 38.3% of emergency procedures. Over the past 5 years, the average length of hospital stay for uncomplicated elective abdominal aortic aneurysms was 6.1 days, intensive care unit stay was 0.7 day, and diet was resumed by postoperative day 1. Five-year graft patency was 99% for aneurysms and 95% for occlusive disease. Conclusions The retroperitoneal approach offers certain physiologic advantages associated with minimal disturbance of gastrointestinal and respiratory function, thereby reducing the length of intensive care unit and hospital stay. In addition, its technical advantages and flexibility facilitates visceral and juxtarenal aortic reconstructions without the need for thoracotomy.

Infected aortic aneurysms remain a difficult surgical problem associated with high morbidity and mortality. We report three cases of mycotic thoracoabdominal aneurysms treated by debridement of infected aortic tissue, in situ prosthetic graft replacement, and intensive antibiotic therapy. One early death occurred in a patient with systemic sepsis related to Salmonella enteritidis infection of the thoracic aorta secondary to a colovesical fistula. The two other patients remain alive at 2 years without further complications of the surgery. Bacteriology is as follows: Staphylococcus aureus, Streptococcus pneumoniae, and Salmonella enteritidis. In all patients the operation was performed immediately after the diagnosis was confirmed. Antibiotic therapy was begun intraoperatively and was continued for at least 6 months. Two patients were followed regularly, and there have been no septic recurrences in our 2-year follow-up period. In situ prosthetic graft replacement in conjunction with intensive antibiotic therapy is a viable option in the treatment of mycotic thoracoabdominal aortic aneurysms.

OBJECTIVE: The authors evaluated the long-term patency and outcome of patients undergoing infrainguinal reconstruction using the in situ saphenous vein. SUMMARY BACKGROUND DATA: The in situ saphenous vein bypass has demonstrated excellent patency and limb salvage rates in numerous studies. The authors previously reported their early results with these bypass procedures, and this article represents their long-term experience with 2058 in situ saphenous vein bypasses during a 20-year period. This comprises the largest series with long-term follow-up of in situ saphenous vein bypasses in the literature. METHODS: From 1975 to 1995, 3148 autogenous vein bypasses were performed at the authors' institution, of which 2058 used the saphenous vein in situ. The indication for operation was limb-threatening ischemia in 1875 of 2058 patients (91%). In 88% of patients with an intact ipsilateral saphenous vein, an in situ bypass was completed successfully. One thousand twenty-three bypasses (69%) were terminated at the infrapopliteal level. Of these bypasses, 1562 of 2058 (76%) were completed using the closed in situ technique. RESULTS: The 30-day patency rate was 96%, and the cumulative secondary patency was 91%, 81%, and 70% at 1, 5, and 10 years, respectively. Limb salvage rates using the in situ bypass were 97%, 95%, and 90% at 1, 5, and 10 years, respectively. CONCLUSION: The infrainguinal inflow source, length of bypass, specific outflow vessel, or vein diameter did not have a significant effect on immediate or long-term bypass performance. These data suggest that the in situ saphenous vein is an excellent conduit for femoropopliteal and femoral to infrageniculate bypasses for limb salvage.

While elective repair of abdominal aortic aneurysms and aortoiliac occlusive disease is associated with an acceptable (3%) mortality rate, combined aortic and renal revascularization has usually been reported to have a higher perioperative mortality. Over the past 5 years, 785 elective aortic procedures have been performed at the authors' medical center. During the same period, 77 renal artery reconstructions have been performed in 73 patients in conjunction with aortic procedures. All were done using the retroperitoneal approach to the aorta and renal arteries. Indication for concomitant renal artery revascularization included 79% (61 of 77 patients) for either significant stenosis or anatomic involvement, 18% for renovascular hypertension (14 of 73) and 3% (two of 73) for renal impairment. The demographics and risk factors were similar in both groups. Operative mortality rate was 2.9% (23 of 785) in the aortic group and 3% (two of 73) in the combined group. Complications in the combined group were one stroke (1.4%), one re-exploration for bleeding (1.4%), two pulmonary pneumonia (2.7%) and five patients had elevated serum creatinine (>350 μmol/l) after operation. Of these patients two died, one had an occluded graft and two eventually improved. There was one early graft thrombosis and one late thrombosis. In the authors' experience, concominant aortic bypass and renal artery revascularization can be performed with an acceptable-mortality and morbidity using the retroperitoneal approach.

We report the case of a 68-year-old male who presented to our emergency department with severe acute testicular pain and syncope. A precipitous fall in his hematocrit along with the presence of a pulsatile expansile abdominal mass prompted the diagnosis of ruptured aortic aneurysm (AAA). He underwent emergency repair of the AAA and was subsequently discharged after an uneventful hospital stay. Our case demonstrates an unusual presentation of ruptured AAA, which is potentially lethal if unrecognised.

Diabetic foot lesions are caused by neurologic, orthopaedic, immunologic, and vascular derangements. Whereas some lesions may be initially caused by trauma and others directly caused by vascular disease, improvement of arterial perfusion often plays an important role in the successful salvage of these limbs. Fortunately, in the last several years, there has been a major improvement in the identification and treatment of those patients in whom correction of arterial occlusive disease is necessary for healing.

The most frequently used conduit for infrainguinal or coronary artery bypass is the saphenous vein, and this report describes the ultrasonic evaluation of anatomic variations in over 1400 limbs. The thigh portion of the greater saphenous vein consisted of a single venous conduit in 67% of the limbs, a complete double system in 8%, a branching double system in 18% and a closed loop double system in 7%. In 92% of the cases, the vein was in medial position, with the remaining 8% positioned laterally. In the calf, a single vein was observed in 65% of the limbs with the remainder demonstrating a double venous system. The vein was positioned anteriorly in 85% of the limbs. The remaining 15% were positioned posteriorly, with 7% of these being a single dominant vein. Proper knowledge of saphenous vein anatomy is vital to the surgeon preparing to use this vein as a bypass conduit and can aid in its preoperative assessment.

Blunt trauma to the upper extremity may cause extensive vascular damage in addition to severe musculoskeletal injury. Over a 5.5-year period, 17 patients with a total of 23 arterial injuries were treated. Diagnosis was made in 16 patients before surgery by physical and Doppler ultrasonographic examination. Angiography performed in ten patients assessed the extent of injury. Associated orthopedic injuries were present in 11 patients and neurologic injury in 16. At surgery, 21 of 23 arterial repairs required autologous vein. The initial limb salvage rate was 76%. Four patients underwent above-elbow amputation because of progressive sepsis and myonecrosis. A fifth underwent delayed amputation at 7 months due to loss of limb function. Neurologic impairment was the major long-term morbidity. The data show that outcome following blunt vascular trauma of the upper extremity is governed by the associated injuries.

Detailed DNA sequencing of the triple-helical domain of type III procollagen was carried out on cDNA prepared from 54 patients with aortic aneurysms. The 43 male and 11 female patients originated from 50 different families and five different nationalities. 43 patients had at least one additional blood relative who had aneurysms. Five overlapping asymmetric PCR products, covering all the coding sequences of the triple-helical domain of type III procollagen, were sequenced with 28 specific sequencing primers. Analysis of the sequencing gels revealed only two nucleotide changes that altered the structure of the protein. One was a substitution of threonine for proline at amino acid position 501 and its functional importance was not clearly established. The other was a substitution of arginine for an obligatory glycine at amino acid position 136. In 40 of the 54 patients, detection of a polymorphism in the mRNA established that both alleles were expressed. The results indicate that mutations in type III procollagen are the cause of only about 2% of aortic aneurysms.

Since 1970, we have treated 43 patients with infected aortic grafts. Early in the series, four patients were treated with resection of the fistula or erosion and systemic and topical antibiotics without removal of the graft. All four patients died. Thirty-two patients were treated by conventional therapy; there were 13 deaths (40 percent). More recently, seven patients were managed by the left retroperitoneal placement of a new in-line polytetrafluoroethylene (PTFE) aortic graft through clean tissue planes, followed by the immediate transperitoneal removal of the infected graft without cross-contamination. Patients were maintained postoperatively on antibiotics for a minimum of two weeks. All seven patients survived without septic complications, with a mean follow-up time of 36 months (six months to four years). The surgical technique consists of initial suprarenal control of the aorta, followed by infrarenal division and oversewing of the distal aorta. A PTFE bifurcation graft is placed connecting the proximal aorta and the appropriate femoral vessels, the right limb tunneled through the space of Retzius. After closure of the incisions, through the space of Retzius. After closure of the incisions, the patient is placed in the supine position and the infected graft is removed transperitoneally. We believe that retroperitoneal in-line aortic bypass for treatment of an infected aortic graft offers a favorable alternative to conventional therapy by avoiding the use of an extra-anatomic bypass and associated risk of stump blowout.

Long vein bypass from the femoral artery to the level of the ankle may be performed with good initial success despite extreme bypass length and limited outflow tracts. However, the long-term performance of these bypasses remains to be defined. During the last 10 years we have performed single greater saphenous vein in situ bypass to the ankle level in 270 patients. There were 187 male and 83 female patients, and 61% of the patients were diabetic. The operative mortality rate was 3.7%. Cumulative bypass patency was 79% at 3 years and 73% at 5 years. In a similar manner, limb salvage was 93% at 3 years and 89% at 5 years. The patency rate was similar for various inflow arteries (common femoral, 88 cases; proximal superficial femoral, 135 cases; and deep femoral, 41 cases) and outflow tracts (dorsal pedal, 72 cases; anterior tibial, 59 cases; posterior tibial, 72 cases, and peroneal, 67 cases). Short bypasses, composite bypasses, free-vein grafts, and bypasses proximal to 10 cm above the ankle were excluded from this analysis. These data show that a long bypass to the ankle level for limb salvage is a durable procedure. The basic concept of bypassing all occlusive disease to the distal open artery in patients undergoing limb salvage should be an acceptable dictum. Excellent long-term patency and limb salvage rates are achievable by following this principle.

A prospective randomized study has been carried out to compare the retroperitoneal (RP) and the transperitoneal (TP) approaches to infrarenal abdominal aortic aneurysms (AAA). From November 1988 to July 1989, 27 patients were randomized to one or the other group. Twelve patients underwent TP resection of their AAA; 11 of these were performed using the open aneurysmorrhaphy technique. The RP approach was used in 15 patients, 12 of whom had the exclusion technique performed. Enteral feeding was resumed on the second postoperative day in the RP group compared to the fourth postoperative day in the TP group; the difference was statistically significant (p less than 0.02). Statistically significant differences were also present in the estimated blood loss (516 cc in the RP group versus 1127 cc in the TP group) in the blood transfusion requirement (p less than 0.05). This prospective randomized study comparing TP and RP approaches to AAA showed that the RPE approach had less blood loss, less transfusion requirement, and earlier resumption of enteral feeding than the TP approach. We feel the RPE technique is safe and efficient in the treatment of infrarenal abdominal aortic aneurysm.