Objective: the purpose of this study is to compare Magnetic Resonance Angiography (MRA) to Duplex Ultrasound Arterial Mapping (DUAM) and intraoperative findings to determine the clinical, accuracy of ...MRA for planning lower extremity revascularization procedures. Methods: forty-two patients who underwent lower extremity revascularization procedures had both MRA and DUAM evaluations. These data were analyzed retrospectively and two distinct endpoints were considered. First, we compared the MRA and DUAM findings for aorto-iliac, femoral-popliteal and infra-popliteal segments to intraoperative findings and evaluated the degree to which they agreed. Second, if there was a disagreement between imaging modalities, it was established whether a change in operative procedure would have resulted. Results: MRA and DUAM findings agreed in 26 of 31 cases (83%) of aorto-iliac segments, in 25 of 31 cases (81%) of femoral-popliteal segments, and in 16 of 21 cases (76%) of infra-popliteal segments. In total, DUAM agreed with intraoperative findings in 98% of cases while MRA agreed in 82% (p<.001). Disagreement between intraoperative findings and DUAM lead to an alternate surgical procedure in only one case (2%) while disagreement with MRA lead to a different procedure in 38% of cases (p<.001). Conclusions: these data show that MRA is not yet adequate to replace conventional angiography and is less accurate that DUAM. Further improvements are necessary before MRA can be used as the sole modality for formulation of a pre-operative plan for lower extremity revascularization.
Eur J Vasc Endovasc Surg 25, 139–146 (2003)
Purpose: previously we routinely performed endarterectomy of the external carotid artery (ECA) during carotid surgery. However, discouraging experience and lack of supportive data in the literature ...made us question its necessity. The present report describes our experience with a modified carotid endarterectomy (CEA) technique where the ECA is left undisturbed regardless of its degree of stenosis. Methods: from January 1996 to June 2001, 1027 CEAs were performed in 905 patients with this technique at our institution. All operations were performed for at least 60% internal carotid artery (ICA) stenosis. A preoperative carotid duplex scan was available for review in 990 cases (96%). Follow-up duplex scans were recovered from 0 to 1 months in 851 cases (83%) and from >1 month in 655 cases (64%). Seventy percent of these cases were performed for asymptomatic lesions. Results: the perioperative (30-day) mortality rate for the entire group of patients was 0.5% and the stroke rate was 0.7%. Mean follow-up was 18 months (range: 2-66 months). Only two ECAs occluded in the first postoperative month. During the follow-up period, 37 additional ECAs (5.6%) were found to progress from mild to severe (>75%) stenosis post-operatively. In addition, 7% of the cases were found to have worsened the degree of stenosis, 8% improved and 85% remained unchanged. Conclusion: these data support sparing of the ECA during CEA.
Eur J Vasc Endovasc Surg 25, 458-461 (2003)
Purpose: The safety, effectiveness and cost issues of carotid endarterectomy (CEA) in the elderly patient have been debated due to the limited life expectancy and presumably increased rate of ...complications. This is despite multiple reports in the literature of excellent results in this population. To further examine this issue, we compared characteristics of three populations who underwent CEA at our institution: 53-79 year old patients (youngest group), 80-89 years old patients (middle group), and 90-98 year old patients (oldest group).
Methods: Medical and financial data were obtained by retrospective review of hospital charts and billing records. We analyzed 266 random CEAs performed in 251 patients in the youngest group, 280 CEAs performed in 247 patients in the middle group and 19 CEA in 16 patients in the oldest group performed between 2/1/90 and 2/5/01. Results: Comparing each CEA group, there were no differences in gender (males: 56% vs. 51% vs. 53%), incidence of preoperative symptoms (43% vs. 43% vs. 42%), hypertension (68% vs. 60% vs. 42%), combined perioperative death and stroke rate (1.8% vs. 2.1% vs. 10%) or other complications (11% vs. 10% vs. 10%). Significant differences (p<0.05) were noted between the groups in incidence of diabetes (33% vs. 51% vs. 5% in each group), and heart disease (28% vs. 38% vs. 21%). Length of stay for admissions for CEA only were also similar in all three groups (2.37 days vs. 2.67 days vs. 2.36 days). A cost analysis of the earliest 230 patients in the entire series examining hospital cost per case revealed similar data for the <80 years old and > 80 year old patients ($7,842 vs. $9,400).
Conclusions: Carotid endarterectomy can be performed in the elderly as safely and cost effectively as in the younger population.
Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; “closure”) is a relatively new option for treatment of venous reflux. However, our initial enthusiasm for this minimally invasive ...technique has been tempered by our preliminary experience with its potentially lethal complication, deep venous thrombosis (DVT).
Seventy-three lower extremities were treated in 66 patients with GSV reflux, between April 2003 and February 2004. There were 48 (73%) female patients and 18 (27%) male patients, with ages ranging from 26 to 88 years (mean, 62 ± 14 years). RFA was combined with stab avulsion of varicosities in 55 (75%) patients and subfascial ligation of perforator veins in 6 (8%) patients. An ATL HDI 5000 scanner with linear 7-4 MHz probe and the SonoCT feature was used for GSV mapping and procedure guidance in all procedures. GSV diameter determined the size of the RFA catheter used. Veins less than 8 mm in diameter were treated with a 6F catheter (n = 54); an 8F catheter was used for veins greater than 8 mm in diameter (n = 19). The GSV was cannulated at the knee level. The tip of the catheter was positioned within 1 cm of the origin of the inferior epigastric vein (first GSV tributary). All procedures were carried out according to manufacturer guidelines.
All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 ± 6 days) after the procedure. The duplex scans documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). Eleven patients (92%) had an extension of the occlusive clot filling the treated proximal GSV segment, with a floating tail beyond the patent inferior epigastric vein into the common femoral vein. Another patient developed acute occlusive clots in the calf muscle (gastrocnemius) veins. Eight patients were readmitted and received anticoagulation therapy. Four patients were treated with enoxaparin on an ambulatory basis. None of these patients had pulmonary embolism. Initially 3 patients with floating common femoral vein clots underwent inferior vena cava filter placement. Of the 19 limbs treated with the 8F RFA catheter, GSV clot extension developed in 5 (26%), compared with 7 of 54 (13%) limbs treated with the 6F RFA catheter (
P = .3). No difference was found between the occurrence of DVT in patients who underwent the combined procedure (RFA and varicose vein excision) compared with patients who underwent GSV RFA alone (
P = .7). No statistically significant differences were found in age or gender of patients with or without postoperative DVT (
P = NS).
Patients who underwent combined GSV RFA and varicose vein excision did not demonstrate a higher occurrence of postoperative DVT compared with patients who underwent RFA alone. Early postoperative duplex scans are essential, and should be mandatory in all patients undergoing RFA of the GSV.
To elucidate the natural history of upper extremity deep venous thrombosis (UEDVT), we examined factors that may contribute to the high mortality associated with UEDVT.
Five hundred forty-six ...patients were diagnosed with acute internal jugular/subclavian/axillary deep venous thrombosis from January 1992 to June 2003 by duplex scanning at our institution. There were 329 women (60%). The mean age ± SD was 68 ± 17 years (range, 1–101 years). Risk factors for UEDVT were the presence of a central venous catheter or pacemaker in 327 patients (60%) and a history of malignancy in 119 patients (22%). Risk factors for mortality within 2 months of the diagnosis of UEDVT that were analyzed included age, sex, presence of a central venous catheter or pacemaker, history of malignancy, location of UEDVT, concomitant lower extremity deep venous thrombosis, systemic anticoagulation, placement of a superior vena caval filter, and pulmonary embolism.
The overall mortality rate at 2 months was 29.6%. The number of patients diagnosed with pulmonary embolism by positive ventilation/perfusion scan or computed tomographic scan was 26 (5%). The presence of a central venous catheter or pacemaker (
P < .001), concomitant lower extremity deep venous thrombosis (
P = .04), not undergoing systemic anticoagulation (
P = .002), and the placement of a superior vena caval filter (
P = .02) were associated with mortality within 2 months of the diagnosis of UEDVT by univariate analysis. Pulmonary embolism (
P = .42), sex (
P = .65), and a history of malignancy (
P = .96) were not.
These data suggest that the high associated mortality of UEDVT may be due to the underlying characteristics of the patients’ disease process and may not be a direct consequence of the UEDVT itself.
Objective: Early stroke occurs in 0.9% to 7% of patients undergoing carotid endarterectomy (CEA). These have been thought to be mostly due to embolization. However, in our recent clinical experience, ...we noted hyperperfu-sion syndrome to be a significant cause of postoperative strokes. Therefore, we reviewed our experience and investigated the distribution of causes of early postoperative strokes.
Materials and methods: A retrospective chart review of 444 consecutive patients who underwent CEA at our institution between June 1997 and October 1999 (500 operations) was performed to evaluate the incidence and etiology of early postoperative strokes. Indications for operation included history of stroke correlating with the side of ICA stenosis (50 patients or 10%), symptoms of transient ischemic attacks (84 patients or 16.8%), amaurosis fugax (18 patients or 3.6%), or asymptomatic stenosis (348 patients or 69.6%). All patients were evaluated with duplex scan preoperatively and postoperatively. Diagnosis of early postoperative strokes within one month after CEA was made based on clinical examination. Postoperative CT scan of the brain was available in 100% of patients with suspected diagnosis of CVA. Results: Five patients (3 male and 2 female) were diagnosed with strokes postoperatively (1%). These five were symptomatic patients with ICA stenosis > 80% and moderate contralateral ICA stenosis. In two of those patients (40%), the reason for the stroke was considered embolization to the cerebral arteries; one patient suffered a shunt injury as a cause of stroke; two patients (40%) were diagnosed with hyperperfusion syndrome. In both patients diagnosis was made clinically, and in only one of those patients the clinical picture correlated with CT scan. Two patients (0.4%) had asymptomatic ICA occlusion at 2 weeks and 18 days postoperatively.
Conclusion: Embolization to the cerebral arteries remains the leading cause of early postoperative strokes. However, hyperperfusion syndrome also accounts for a significant portion of these postoperative strokes. The percentage of patients with this syndrome might be even higher, once clinical picture is clearly defined. These data warrant further investigation of hyperperfusion syndrome.
Since the data investigating endovascular therapy performed by surgeons is scarce, we retrospectively reviewed our experience of endovascular procedures performed by vascular surgeons in the ...operating room for lower extremity ischemia due to stenotic lesions.
Methods: A total of 14,424 procedures were performed by our division between January 1990-October 2003. Of these, 500 involved a balloon angioplasty. These made up 3.5% of the total caseload. The median age of the patients who underwent these 500 balloon angioplasty was 72 ±0.5 years old; 65% were male; 50% had a history of diabetes mellitus, and 6% had ESRD. Indications for the procedures included acute ischemia (47 cases), critical ischemia (rest pain, gangrene, or ischemic ulcers in 254 cases), failing bypass (64 cases), severe claudication (134 cases), and preoperative for a popliteal artery aneurysm repair.
Results: 244 of the procedures were percutaneous, and the remaining 256 were combined with some type of open procedure. Those performed as an open technique were in combination with a bypass (135 cases) and in combination with a patch angioplasty (31cases). Balloon angioplasties were performed of the aorta (5 cases), iliac arteries (281 cases), the superficial femoral artery (SFA) (101 cases), the popliteal artery (44 cases), the tibial vessels (77 cases), the subclavian/axillary artery (5 cases) and failing grafts (26 cases). Balloon angioplasty was attempted in eight cases and failed due to inability to cross the lesion with a guidewire. Intraoperative complications included 4 dissections, inability to dilate the lesion adequately (2 cases), and rupture of two iliac lesions that underwent open repair (1 case) or repair with a stent graft (1 case). Stents were initially used highly selectively but recently are now being deployed more liberally in the iliac arteries (total 251 cases with stents).
Conclusions: Based on these data, we suggest that balloon angioplasty is a useful tool that can be performed by vascular surgeons safely. The advantages to the patients include one combined procedure to treat lower extremity ischemia.
Purpose: It is believed that cerebral hyperperfusion syndrome (CHS) is caused by loss of cerebral autoregulation resulting from chronic cerebral ischemia and that factors including increased ...intraoperative cerebral blood flow, ipsilateral or contralateral carotid disease, and postoperative hypertension may cause CHS. We describe our experience with CHS, which diverges from published reports. Materials and methods: From March 2000 to February 2002 we performed 455 carotid endarterectomy (CEA) procedures in 404 patients at our institution. CHS developed 1 to 8 days (mean, 3.2 ± 2.5 days) postoperatively in 9 patients (2%), 6 women and 3 men, whose age ranged from 52 to 84 years (mean, 69 ± 8 years). Indications for surgery in 8 patients without neurologic symptoms were ipsilateral internal carotid artery (ICA) stenoses ranging from 70% to 99% (mean, 80% ± 7%); the remaining patient had an ipsilateral stroke, with good clinical recovery, 7 weeks before CEA. Only 1 patient had significant contralateral ICA stenosis (70%). However, 5 patients had undergone contralateral CEA within the previous 3 months. CHS symptoms were severe headache in 5 patients, seizures in 3 patients (1 stroke), and visual disturbance and ataxia in 1 patient. All 404 patients (455 cases) underwent intraoperative and early (2 weeks) postoperative carotid artery duplex scanning. The 9 patients with CHS also underwent carotid artery duplex scanning at the time of the neurologic event. Results: Mean intraoperative ICA volume flow (MICAVF) in the 9 CHS cases was not significantly different from that in the other 446 cases (170 ± 47 mL/min and 182 ± 81 mL/min, respectively). However, mean ICA volume flow (481 ± 106 mL/min) and peak systolic velocity (PSV) (108 ± 33 cm/s) for the 9 CHS cases measured at onset of symptoms were higher than those for the remaining 446 cases (267 ± 87 mL/min and 80 ± 26 cm/s, respectively) (P <.01). Of the 9 patients with CHS, only 3 had systolic blood pressures more than 160 mm Hg at onset of symptoms. Severity of ipsilateral and contralateral ICA stenoses was not significantly different between the 9 CHS cases and the remaining 446 cases. Conclusions: These data do not corroborate the common belief that CHS occurs preferentially in patients with severe ipsilateral or contralateral carotid disease, increased intraoperative cerebral perfusion, or severe hypertension. Recently performed contralateral CEA (<3 months) appears to be predictive of CHS. (J Vasc Surg 2003;37:769-77.)
In an effort to explore alternatives to contrast material–enhanced arteriography, we compared magnetic resonance angiography (MRA) and duplex arteriography (DA) with contrast arteriography (CA) for ...defining anatomic features in patients undergoing lower extremity revascularization.
From August 1, 2001, to August 1, 2002, 61 consecutive inpatients (64 limbs) with chronic lower extremity ischemia underwent CA, MRA, and DA before undergoing lower extremity revascularization procedures. The reports of these tests and images were compared prospectively, and the differences in the iliac, femoropopliteal, and infrapopliteal segments were noted. The vessels were classified as mildly diseased (<50%), moderately diseased (50%-70%), severely diseased (71%-99%), or occluded. The studies and treatment plans based on these data were compared.
Mean patient age was 76 ± 10 years (SD). Indications for the procedures included gangrene (43%), ischemic ulcer (28%), rest pain (19%), severe claudication (9%), and failing bypass (1%). During this period 35 patients were ineligible for the protocol, because they could not undergo MRA (n = 27) or angiography (n = 8). Of the total 192 segments in the 64 patients (iliac, femoropopliteal, tibial), 17% were not able to be fully assessed with DA, and 7% with MRA. Disagreements with CA and DA were found in the iliac, femoropopliteal, and tibial segments in 0%, 7%, and 14% of cases, respectively, and between CA and MRA in 10%, 26%, and 42% of cases, respectively. Two of 9 differences (22%) between DA and CA were thought to be clinically significant, and 28 of 45 differences (62%) between MRA and CA were thought to be clinically significant.
A review of the data obtained in this series indicates that MRA does not yet seem to yield adequate data, at least in this highly selected population at our institution. When severe calcification is identified, CA may be necessary in patients undergoing DA.
Balloon angioplasties of stenotic or occluded infrapopliteal arteries may be helpful in selected high-risk patients threatened with limb loss. Thus far, these procedures have demanded fluoroscopy and ...the injection of potentially nephrotoxic contrast material. Herein, we proposed a new alternative to avoid the harmful effects of radiation exposure and the risk of acute renal failure.
Over the last 16 months, 30 patients (57% male) aged 74 ± 9 years (mean ± SD) had a total of 52 attempted balloon angioplasties of the infrapopliteal arteries in 32 limbs under duplex guidance. Indications for the procedure were critical ischemia in 20 limbs (63%), including rest pain, ischemic ulcers, and gangrene in 4 (13%), 10 (31%), and 6 (19%) limbs, respectively. Severe disabling claudication was an indication in the remaining 12 limbs (37%). All patients had concomitantly performed balloon angioplasties of the superficial femoral and popliteal arteries (28 cases) or the popliteal artery alone (4 cases). Balloon angioplasty of the infrapopliteal arteries was performed as an adjunct to improve runoff. Hypertension, diabetes, renal insufficiency, smoking, and coronary artery disease were present in 77%, 73%, 50%, 47%, and 37% of cases, respectively. There were 42 cases (81%) with infrapopliteal arterial stenoses (25 tibioperoneal trunks, 9 peroneal arteries, 4 anterior tibial arteries, and 4 posterior tibial arteries) in 26 limbs. The remaining 10 cases (19%) had infrapopliteal arterial occlusions (4 tibioperoneal trunks, 5 peroneal arteries, and 1 anterior tibial artery) in 6 limbs. All these cases were combined with more proximal endovascular procedures (21 femoropopliteal stenoses and 11 femoropopliteal occlusions). All patients had preprocedure duplex arterial mapping and ankle/brachial index (ABI) measurement. Local anesthesia with light sedation was used in all cases. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery and distally, beyond the infrapopliteal diseased segment. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to the arterial measurements obtained by duplex guidance. Completion duplex examinations were performed and postprocedure ABIs were obtained in all cases.
Although the overall technical success was 94% (49/52 cases), it was 95% for those with stenoses (40/42 cases) and 90% for those with occlusions (9/10 cases; P < .5). Intraoperative thrombosis occurred in three infrapopliteal cases (two tibioperoneal trunks and one peroneal artery) and in one popliteal artery. All four cases were successfully managed with intra-arterial infusion of thrombolytic agents under duplex guidance. Overall, the preprocedure and postprocedure ABIs ranged from 0.4 to 0.8 (mean ± SD, 0.58 ± 0.15) and 0.7 to 1.1 (mean ± SD, 0.9 ± 0.16), respectively (P < .0001). Twenty-two (88%) of 25 patients experienced a significant (>0.15) postoperative ABI increase. Overall 30-day survival and limb salvage rates were 100%.
The proposed technique eliminates the need for radiation exposure and the use of contrast material, and it seems to be an effective alternative approach for the treatment of infrapopliteal occlusive disease. Additional advantages include accurate selection of the proper size of balloon and confirmation of the adequacy of the technique by hemodynamic and imaging parameters.
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