Technique for obtaining proximal intraluminal control when arteries are inaccessible or unclampable because of disease or calcification

Penetrating intracranial trauma of two minors treated with endovascular technique with the use of temporary balloon occlusion for proximal arterial control

We present two children treated with endovascular techniques to gain proximal arterial control of the internal carotid and vertebral artery prior to removal of penetrating objects from the skull base. Both siblings (8-month-old and 22-month-old boys) were injured by different sharp objects (knife and scissor) by a guardian. They were transported to the emergency room where vascular control, including coil embolisation and internal carotid balloon occlusion, was performed in the neuroendovascular suite for safe removal of penetrating objects. Both minors recovered and were discharged home without any focal neurological deficits. In two children with scissor and knife stab with intracranial penetration, endovascular technique allowed safe removal of objects and ensured proximal arterial control was maintained to control for possible extravasation of blood on removal from the skull base.

Femoral Artery to Prosthetic Graft Anastomotic Dehiscence Owing to Infection: Successful Treatment with Arterial Reconstruction and Limb Salvage

A 66-year-old man had foot gangrene and a fixed contracture of the knee following two failed femoropopliteal bypasses, one with vein and one with polytetrafluoroethylene (PTFE). An external iliac to anterior tibial artery bypass and skeletal traction via the os calcis resulted in limb salvage and successful normal ambulation. After 3 months, he ruptured the infected femoral anastomosis of the failed PTFE femoropopliteal bypass with external bleeding. The use of arteriography and a balloon catheter to obtain proximal control allowed arterial repair, removal of the graft, and preservation of flow within a patent common and deep femoral artery. This flow preservation maintained the viability and function of the limb when the anterior tibial bypass closed 4 years later, and the limb continues to be fully functional 3 years later. Aggressive secondary attempts at limb salvage are worthwhile even in unfavorable circumstances.

Early endovascular grafts at Montefiore Hospital and their effect on vascular surgery

Vascular surgery is very fortunate. It recognized the transition from open surgery to endovascular procedures as treatments for vascular disease early enough to adapt as a specialty. As a result, most vascular surgeons in North America became competent with endovascular techniques, and the survival of the specialty was assured. The endovascular graft program at Montefiore Hospital played a major role in vascular surgery's early recognition of the importance of the endovascular revolution. This article will review the history of this early endovascular graft program and how it influenced the specialty.

Triple-wire: a variation of the "Preclose" technique

We describe a technical modification of the "Preclose" technique that changes the cross-pattern sutures created with the Prostar XL as in a previously described variation using the Proglide device for longitudinal interrupted sutures. This technique was used in 19 femoral arteries, with satisfactory hemostasis achieved in 17. The variation we describe creates a percutaneous longitudinal interrupted suture that closely resembles a surgical interrupted suture. It adds minimal operative time, no additional technical demands, and no significant material cost. Additionally, it allows better control over suture placement and insertion of a balloon catheter for better proximal bleeding control.

Digital fluoroscopy as a valuable adjunct to open vascular operations

The increasing availability of and vascular surgeons' familiarity with digital cine-fluoroscopy in the operating room has been facilitated by the advent and growing popularity of endovascular aortoiliac aneurysm repair and other endovascular techniques that are being incorporated into vascular surgical practice. Digital cine-fluoroscopy can also be used as a valuable adjunct to standard open vascular procedures in several ways including: performance of completion angiography, fluoroscopically-assisted thromboembolectomy, intraoperative planning angiography, fluoroscopically-guided pressure gradient measurements, achieving vascular control of proximal arteries, intraoperative thrombolysis of compromised outflow tracts, and angioplasty and stenting of lesions detected intraoperatively. These techniques can improve the outcome of standard vascular procedures by permitting the identification of inflow, outflow, conduit, and anastomotic defects intraoperatively and guiding their repair. Additionally, in many cases they can reduce the amount of exposure required, reduce intraoperative blood loss, and minimize trauma to vessels during thrombectomy. Fluoroscopic guidance can facilitate and improve these and other aspects of standard open vascular procedures. Conversely, the ability to perform open interventions can facilitate the performance of many endovascular interventions. It is becoming increasingly important to be facile with both open and E fluoroscopically guided techniques in order to fully treat the spectrum of vascular disease in an optimum fashion.

Prosthetic patch remnants to treat infected arterial grafts

PURPOSE

Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants.

METHODS

During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2- to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months).

RESULTS

No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible.

CONCLUSION

Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.

Use of digital ciné-fluoroscopy and catheter-directed techniques to improve and simplify standard vascular procedures

Digital ciné-fluoroscopy and catheter-directed treatments have become indispensable tools in the armamentarium of surgeons performing vascular procedures. These new technologies not only improve and simplify the performance of standard vascular operations but also allow surgeons to perform a wide range of interventions previously unavailable in the operating room.