Purpose: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional ...outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved.
Methods: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia.
Results: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations.
Conclusions: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent. (J Vasc Surg 1998;27:256-66.)
Introduction: Detailed information on functional outcome after open abdominal aortic aneurysm (AAA) repair is sparse. Information about functional outcome of open AAA repair is essential to allow ...comparison of treatment modalities. Methods: To determine the functional outcome of patients after open repair of AAA, we reviewed 154 consecutive, nonemergency open repairs of infrarenal AAAs between 1990 and 1997 and each patient's medical records. Clinical variables were recorded for each patient, as were multiple outcomes, including ambulatory status, independent living status, current medical condition, and the patient's perception of recovery and satisfaction. Eighty-seven patients or their families were available for current telephone interview to obtain information about objective functional activities, including walking and driving, and subjective functional information, including assessment of complete recovery and willingness to undergo AAA repair again. Chart data were available for all 154 patients. Results: There were 42 women and 112 men. A total of 139 operations were elective, and 15 were urgent. The operative mortality rate was 4%, mean hospital stay was 10.7 ± 1.3 days, and mean intensive care unit stay was 4.57 ± 1.17 days. Seventeen (11%) patients required transfer to a skilled nursing facility with a mean stay of 3.66 ± 2.9 months. All patients were ambulatory preoperatively, whereas at last follow-up (median, 25 months; range, 0.13-108.5 months), 100 (64%) of the patients remained ambulatory, 34 (22%) required assistance, and 12 (14%) were nonambulatory. At current assessment by telephone interview, 33% of patients described a decrease in their functional activity including driving, shopping, and traveling compared with their preoperative status, whereas 67% were unchanged. When asked to assess their own degree of recovery, 64% of patients stated that they experienced complete recovery with an average time to recovery of 3.9 months, whereas 33% said they had not fully recovered at a mean follow-up of 34 months. Sixteen (18%) patients said they would not undergo AAA repair again knowing the recovery process, even though they appeared to fully understand the implication of AAA rupture. Conclusion: Patients undergoing open AAA repair generally experienced significant freedom from surgical complications. However, substantial functional impairment was present. It is unclear whether the functional disability resulted from the AAA surgery or from aging and comorbidities unrelated to surgery. (J Vasc Surg 2001;33:913-20.)
Purpose: There have been few studies of the natural history of peripheral arterial disease (PAD), and none have used serial noninvasive laboratory examinations for the objective quantification of ...disease progression. The relationship between the site of initial symptoms of PAD (lower-extremity disease LED vs cerebrovascular disease CVD) and the site of subsequent symptomatic progression (LED vs CVD vs coronary heart disease CHD) has not been examined. Methods: This is a long-term, blinded prospective clinical research study of the relationship of PAD progression to multiple clinical, laboratory, and noninvasive vascular laboratory parameters. Patients with symptomatic LED, CVD, or both underwent comprehensive risk-factor assessment and were seen every 6 months for follow-up examinations. In addition to history and physical examination, all subjects underwent serial noninvasive lower-extremity and carotid artery testing. The relationship between the initial symptomatic site(s) and subsequent progression was examined by means of multivariate proportional hazards analysis, which was adjusted for age, diabetes mellitus, hypertension, smoking, cholesterol, homocysteine level, lowest initial ankle/brachial index (ABI), worst carotid stenosis, ABI progression, and carotid stenosis progression, because each of these factors was significantly associated with one or more aspects of progression. Results: There were 397 study subjects (mean age, 66 years; 38% women) with a mean follow-up period of 48.5 months. LED was initially present in 88% of subjects and CVD in 37% of subjects (both were present in 25% of subjects). There were 78 deaths, 47 (60%) of which were caused by cardiovascular disease (18% mortality rate after 5 years by means of life table). Progression of disease as documented by means of vascular laboratory findings occurred in 90% of subjects by means of life table after 5 years (ABI progression, 31%; carotid stenosis progression, 40%). Symptomatic clinical progression of disease occurred in 52% of subjects by means of life table after 5 years (LED progression, 22%; CVD progression, 23%; CHD progression, 31%). By means of multivariate analysis, no significant relationship was found between the site of initial symptoms of PAD and the site(s) of subsequent symptomatic clinical progression (LED vs CVD vs CHD; P = not significant for all hazard ratios). Conclusion: Patients with symptomatic PAD experience symptoms of ongoing LED, CVD, and CHD with a frequency that is not influenced by the site(s) of their original symptoms. The hypothesis that lesions and resulting symptoms of systemic atherosclerosis occur at various anatomic sites as a matter of random chance should be tested with other studies. (J Vasc Surg 2002;35:38-47.)
Purpose: Interest in alternative methods, such as autogenous vein grafts and aortic allografts, for the management of infrarenal aortic infection (IRAI) has been stimulated by the historically ...disappointing results with conventional surgical management. Recently, there have been dramatic improvements in the results of axillofemoral bypass grafting (AXFB) followed by excision of the IRAI that have gone relatively unrecognized. The purpose of this report is the presentation of modern-day results in the treatment of IRAI with conventional surgical methods.
Methods: From January 1, 1983, through June 30, 1998, patients with IRAI underwent treatment with AXFB and complete excision of the IRAI. The patients were followed for survival, limb salvage, and AXFB graft patency. The results were tabulated with life-table methods.
Results: During the 15-year study period, 60 patients (51 men, nine women; mean age, 68 years) underwent treatment for IRAI (50 graft infections, including 16 graft-enteric fistulae, and 10 primary aortic infections). The mean follow-up period was 41 months. The perioperative mortality rate was 13% (12% for graft infection, and 20% for primary infection). The overall 2-year and 5-year survival rates were 67% and 47%, respectively. The limb salvage rates at 2 and 5 years were 93% and 82%, respectively. The 5-year primary AXFB graft patency rate was 73%.
Conclusion: These results show an improvement with the conventional management of IRAI equal or superior to those results reported with alternative methods, including femoral vein grafts or aortic allografts. These results should be regarded as the modern standard with which alternative therapies can be compared. (J Vasc Surg 1999;30:76-83.)
Surgical treatment of infected aortic aneurysm Moneta, Gregory L.; Taylor, Lloyd M.; Yeager, Richard A. ...
The American journal of surgery,
05/1998, Volume:
175, Issue:
5
Journal Article, Conference Proceeding
Peer reviewed
We report results of infected aortic aneurysms treated by a single group over 20 years.
Retrospective review.
Seventeen patients were treated, 10 with infrarenal and 7 suprarenal infections. All had ...abdominal/back pain, 88% wore febrile, 71% had leukocytosis, and 24% were hemodynamically unstable. The most common responsible organism was
Staphylococcus aureus (29%) followed by
Salmonella organisms (24%). All suprarenal infections were gram-positive organisms. Infrarenal infections were treated with preliminary axillofemoral bypass followed by aortic resection. Suprarenal infections were treated with either in situ prosthetic graft or patch repairs. Operative survival was 90% for infrarenal and 57% for suprarenal infections. Operative deaths occurred in the setting of overwhelming sepsis and/or severe preoperative hemodynamic instability. There was no limb loss, renal failure, or intestinal ischemia. Late deaths occurred in 4 patients at 1.3 to 6.3 years postoperatively and were unrelated to their aortic repairs. Nine patients remain alive with a median follow-up of 2 years. There have been no late aortic or graft infections.
In the absence of hemodynamic instability and uncontrolled sepsis, infected aortic aneurysms can be successfully repaired with durable results.
Duplex ultrasonography accurately identifies high-grade stenoses in the SMA. Analysis of velocity data reveals few false positives and virtually no false negatives in the determination of high-grade ...SMA stenosis by duplex scanning. We therefore utilize duplex scanning to perform early screening studies of patients with symptoms suggestive of chronic visceral ischemia. If the duplex findings are negative, we recommend evaluating for other sources of abdominal pain. If the findings are positive, prompt angiography is indicated. It is important to remember that although duplex scanning can identify mesenteric artery stenosis, it cannot diagnose intestinal ischemia. By establishing duplex scanning as a useful and accessible noninvasive screening tool, it is hoped that the time between onset of visceral ischemic symptoms and diagnosis of chronic visceral ischemia will be shortened significantly, potentially reducing the morbidity and mortality of the disease.
It has been shown that both serum triiodothyronine (T3) and plasma fibronectin values decline with fasting and increase with treatment of diabetic ketoacidosis in a paralles manner. To evaluate the ...mechanism responsible for these changes, we examined the effects of both oral T3 administration and fasting in six healthy, adult subjects. Initial plasma fibronectin values were normal in four subjects (group 1) and decreased in two subjects (group 2). Initial serum T3 and thyroxine (T4) values were normal in both groups. Despite a substantial rise in serum T3 values with oral T3 administration, plasma fibronectin fell in group 1 subjects. Fasting caused a significant decline in serum T3 levels, but only a small further decline of plasma fibronectin concentrations. Serum T3 levels rose after 1 week of refeeding, whereas plasma fibronectin levels in group 1 did not return toward normal. Plasma fibronectin values did not change in group 2 subjects with oral T3, fasting, or refeeding. In conclusion, there is no simple cause-and-effect relationship between previously observed changes in plasma fibronectin and serum T3 concentrations. High doses of oral T3 will lower plasma fibronectin levels in subjects with initially normal plasma fibronectin values and a normal caloric intake.
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