Repair of Bilateral Iliac Artery Aneurysms Associated with a Congenital Pelvic Kidney

The association of iliac artery aneurysms with a congenital pelvic kidney is extremely rare. Although multiple techniques are well described for renal preservation with renal ectopia in the setting of aortic reconstruction, few reports exist describing techniques for renal preservation in the setting of bilateral iliac artery aneurysms. A case is presented of a middle-aged man with a 6-cm right common iliac artery aneurysm and a 3-cm left common iliac artery aneurysm and a right pelvic kidney. A double-proximal-clamp technique and temporary shunting to the pelvic kidney were used during the aneurysm repair. The technical aspects of this procedure are presented as well as a brief discussion of the various options for renal preservation with renal ectopia when repairing complex aneurysmal disease.

Case of adolescent with Paget-Schroetter syndrome and underlying thrombophilia due to an elevated lipoprotein (A)

Upper extremity deep vein thrombosis (UEDVT) is a rare disorder in children and is most often associated with a central venous catheter (CVC), cancer, or an underlying thrombophilia. In adults, repetitive or strenuous upper extremity activity has been linked to mechanical compression of the thoracic outlet resulting in subclavian vein thrombosis, also known as Paget-Schroetter Syndrome (PSS). We present the case of a 14 year old female who was found to have an UEDVT consistent with PSS. On subsequent thrombophila screening, she was noted to have a significantly elevated lipoprotein (a) level of 83 (normal: <30 mg/dL). She underwent 3 months of anticoagulation therapy prior to her first rib resection and in follow-up was noted to have complete patency of her subclavian vein. This case illustrates the necessity for thrombophilia screening in the pediatric patient with UEDVT despite evidence of anatomic abnormality or mechanical venous compression.

Physical exam and occult post-traumatic vascular lesions: implications for the evaluation and management of arterial injuries in modern warfare in the endovascular era

Based on complexity of extremity wounds sustained in recent combat, arteriography had been used routinely in evaluations for delayed or occult arterial injuries. This report aims to quantitatively analyze the sensitivity and specificity of physical exam (PE) in predicting the presence of these injuries. United States service members sustaining extremity trauma in the Global War on Terrorism were evacuated to our medical center and evaluated by a senior vascular surgeon. Those with an abnormal PE, at risk based on wounding patterns, or previously treated for vascular injury underwent arteriography. Data from each patient were prospectively entered into a Vascular Injury registry. Comprehensive information about the injuries, interventions, arteriogram results, and any periprocedural complications were analyzed. Twenty-five endovascular or open surgical interventions were performed in forty-six of 99 patients that had lesions on arteriography. Seventy-three patients had a normal PE, of which 36 had lesions that prompted 6 subsequent interventions. Twenty-two of 26 patients with an abnormal PE had lesions that prompted 19 interventions. For PE, sensitivity was 38%, specificity was 90%, and positive predictive value (PPV) and negative predictive value (NPV) were 85% and 51%, respectively. In proximity injuries, PPV improved to 100%, but was only 15% sensitive with a NPV of 60%. In conclusion normal PE did not reliably predict post-traumatic arterial lesions in these military extremity injuries. These lesions are amenable to endovascular therapies, and should be considered in cases of complex trauma involving high amounts of energy, penetrating mechanisms, or wounding patterns in proximity to named vessels.

Percutaneous arterial closure in peripheral vascular disease: a prospective randomized evaluation of the Perclose device

BACKGROUND

Patients with peripheral vascular disease have been excluded from initial studies of percutaneous suture-mediated closure devices (SMCD) despite representing a significant proportion of those requiring endovascular intervention. We sought to determine whether these devices could be safely used in patients with peripheral vascular disease.

METHODS

Patients were stratified into two groups and five subgroups on the basis of indication for arteriography, and they were prospectively randomized at the end of the procedure to receive either the SMCD or manual compression. Ankle-brachial index was determined and duplex ultrasound scanning of the accessed femoral artery was performed, before and after the procedure. Ultrasound data included peak systolic velocity, minimum intraluminal vessel diameter, and presence or absence of calcified plaque. Time to hemostasis, ambulation, and discharge were recorded, and major or minor complications were noted.

RESULTS

Of 102 patients included in the study, 52 patients were randomized to receive the SMCD. There was no difference in ankle-brachial index, minimum intraluminal vessel diameter, or peak systolic velocity in the accessed vessel after closure with SMCD or manual compression. Time to hemostasis, ambulation, and discharge was significantly less in the SMCD group (P =.001). Presence of calcified plaque was not associated with complications (P =.146). In the SMCD group, hemostasis was achieved with 49 of 52 devices (94.2%). There were six complications (5.9%), two of which were major and required operative intervention. All complications were hemorrhagic and not occlusive. There was no difference in overall complication rate between SMCD (7.7%) and manual compression (4.0%) groups (P =.678). No infection was noted in any of the 102 patients.

CONCLUSIONS

Suture-mediated percutaneous arterial closure can be safely performed in patients with peripheral vascular disease, even in the presence of calcified plaque. This closure technique enables shorter time to hemostasis, ambulation, and hospital discharge. There are observed differences in minor, but not major, complication rates for MC versus percutaneous arterial closure in patients with peripheral vascular disease, but these differences did not achieve statistical significance in this small series.

Varicose veins possess greater quantities of MMP-1 than normal veins and demonstrate regional variation in MMP-1 and MMP-13

BACKGROUND

Studies have reported that structural proteins such as elastin and collagen are decreased in varicose veins compared to normal controls. We hypothesized that the changes observed in varicose vein wall composition may be related to alterations in extracellular matrix remodeling proteins, such as the matrix metalloproteases and serine proteases. In addition we hypothesized that there may be regional variation in the expression of these enzymes within the leg.

PATIENTS AND MATERIALS

One-centimeter segments of the proximal and distal greater saphenous vein (GSV) were obtained from patients undergoing ligation and stripping for venous insufficiency (vv) (n = 15) or GSV harvest in conjunction with coronary artery bypass grafting (CABG) (n = 7). All vv patients had incompetence of the GSV by color flow duplex. Vein specimens were examined for MMP-1, 3, and 13, tryptase, and GAPDH mRNA using semiquantitative RT-PCR analysis. Quantification of MMP-1 and 13 (active/latent forms) and tryptase was performed using Western blot analysis. Western blots were analyzed using scanning densitometry and standardized to normal controls and values expressed as the median densitometric index (D.I.). Nonparametric statistical methods (Wilcoxan signed rank test and Mann-Whitney U test) were used for analysis.

RESULTS

We were able to amplify MMP-1, MMP-13, and tryptase mRNA from both proximal and distal segments of all greater saphenous veins studied. MMP-3 mRNA, however, was not found in either segment of any of the veins examined. A semiquantitative analysis of RT-PCR products comparing the ratio of MMP-1, MMP-13, or tryptase mRNA to GAPDH mRNA showed no difference between cases and controls nor proximal vs distal vein segments. Western blot analysis revealed larger quantities of MMP-1 in varicose veins than in nondiseased veins from CABG patients (48.0 +/- 36.7 D.I. vs 12.5 +/- 6.8 D.I., P = 0.036). Investigation into the regional variation of proteases revealed lower amounts of MMP-1 in distal than in proximal vein segments (37.9 +/- 35.0 D.I. vs 44.1 +/- 41.6 D.I., P = 0.01). Similarly, we found significantly less MMP-13 in distal segments of varicose veins than in proximal segments (152.8 +/- 130.0 D.I. vs 206.7 +/- 173.3 D.I., P = 0.006).

CONCLUSIONS

This study found that MMP-1 protein is increased in varicose veins when compared to controls despite no differences in mRNA expression. In addition we found that there is regional variation of MMP-1 and MMP-13 in diseased varicose veins. Lower leg veins have significantly reduced amounts of these proteolytic enzymes when compared to veins of the upper thigh. These data suggest that posttranscriptional regulatory controls could be responsible for the observed differences.

Controlled ischemia for complex venous surgery: the technique of choice

Surgery under controlled ischemia has been extensively practiced by cardiac, plastic, orthopedic, vascular, and general surgeons. During the past 20 years, we have routinely used this technique to operate on a clean, bloodless field in complex cases of congenital vascular malformations. Based on our favorable experience, we have extended the use of the pneumatic tourniquet to complex cases of primary varicose veins. The use of the tourniquet has dramatically decreased the blood loss and operating time in complex venous surgery without complications secondary to its use. This technique represents a welcome alternative to the bloody, tedious, and time-consuming traditional varicose vein surgery of the past. Complex venous surgery for extensive varicose veins of the extremities can be safely and expeditiously performed under controlled ischemia. It should be the technique of choice.

The nutcracker syndrome: its role in the pelvic venous disorders

BACKGROUND

Symptoms of pelvic venous congestion (chronic pelvic pain, dyspareunia, dysuria, and dysmenorrhea) have been attributed to massive gonadal reflux. However, obstruction of the gonadal outflow may produce similar symptoms. Mesoaortic compression of the left renal vein (nutcracker syndrome) produces both obstruction and reflux, resulting in symptoms of pelvic congestion. We describe the diagnosis and management of nine patients studied in our institutions.

MATERIALS AND METHODS

From a group of 51 female patients with pelvic congestion symptoms studied at our institutions, there were nine patients with symptoms of pelvic congestion, microscopic hematuria, and left-sided flank pain. The diagnosis of the nutcracker syndrome was suspected based on clinical examination, Doppler scan, duplex ultrasound scan, computed tomography scan, and magnetic resonance imaging. The diagnosis was confirmed by retrograde cine-video-angiography with renocaval gradient determination and catheterization of both internal iliac venous systems. All patients had a renocaval pressure gradient >4 mm Hg (normal, 0-1 mm Hg). Renal compression was relieved by external stent (ES) in two patients, internal stent (IS) in one patient, and gonadocaval bypass (GCB) in three. GCB was preceded by coil embolization of internal iliac vein tributaries connecting with lower-extremity varicose veins in three patients. Three patients deferred surgery and are under observation. Mean follow-up time was 36 months (range, 12-72 months).

RESULTS

Hematuria disappeared postoperatively in all patients. ES and IS normalized the renocaval gradient and resulted in significant alleviation of symptoms (90% improvement on a scale of 0-10 where 0 = no improvement and 10 = greatest improvement). Two patients with GCB had a residual gradient of 3 mm Hg. The third patient normalized the gradient. In this group, improvement of symptoms was 60%. Patients awaiting surgery are being treated conservatively (elastic stockings, hormones, and pelvic compression). They have shown only moderate improvement.

CONCLUSION

The nutcracker syndrome should be considered in women with symptoms of pelvic venous congestion and hematuria. The diagnosis is suspected by compression of the left renal vein on magnetic resonance imaging or computed tomography scan and confirmed by retrograde cine-video-angiography with determination of the renocaval gradient. Internal and external renal stenting as well as gonadocaval bypass are effective methods of treatment of the nutcracker syndrome. IS and ES were accompanied by better results than GCB. Surgical and radiologic interventional methods should be guided by the clinical, radiologic, and hemodynamic findings.

Bilateral spontaneous dissection of the internal carotid arteries--a case report

A 41-year-old African American man presented with an acute stroke secondary to bilateral spontaneous internal carotid artery dissections following exercise. Spontaneous bilateral carotid artery dissection is an unusual and uncommon occurrence that can be successfully diagnosed by color-flow duplex ultrasonography and magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) imaging. A review of the literature and the authors' experience supports initial medical management of these patients. Surgery should be considered for those patients who exhibit progressive neurologic symptoms during medical management or when significant carotid artery complications, aneurysms, or flow-limiting stenoses persist.

The fate of a patent carotid artery contralateral to an occlusion

The finding of carotid stenosis contralateral to a carotid occlusion is becoming more frequent. While the neurologic outcomes in this patient population have been described, the rate of disease progression measured by duplex examination and the eventual need for carotid endarterectomy has not been described. In this study, a computerized database of carotid duplex examinations was reviewed and clinical data were obtained from clinic records. From 9124 studies 117 patients were identified. Thirty patients had previous carotid surgery on the patent side and were excluded. Of 87 patients 33 required carotid endarterectomy on the patent side. The rate of disease progression and/or the performance of a carotid endarterectomy by life-table analysis was 85.9% over 8 years. There were 10 neurologic events during the follow-up period. Patients with carotid stenosis and contralateral occlusion are at significant risk for disease progression. Follow-up should be more frequent and of longer duration in this patient population. A significant number of patients with carotid artery occlusion will require a carotid endarterectomy of the patent contralateral carotid.

Hemostatic efficacy of fibrin sealant (human) on expanded poly-tetrafluoroethylene carotid patch angioplasty: a randomized clinical trial

PURPOSE

The efficacy of solvent-detergent-treated fibrin sealant (human [FSH]) for controlling anastomotic bleeding from expanded polytetrafluoroethylene (ePTFE) patch angioplasty during carotid endarterectomy was evaluated, and FSH was compared with thrombin-soaked gelatin sponge (Gelfoam; TSG).

METHODS

The study was of a randomized, open-label, single-site, single-treatment, parallel design that took place in a referral center with hospitalized patients. Forty-seven adult patients (33 men, 14 women) underwent elective carotid endarterectomy. Patients were randomized to receive either FSH (N = 24) or TSG (N = 23). FSH was obtained as an investigational new drug. FSH was applied as a liquid by means of a dual-syringe technique. Heparin anticoagulation, patch thickness, and suture type were standardized. Two different needle sizes were used (CV-6, PT-13: N = 21 [FSH: N = 10, TSG: N = 11]; CV-6, PT-9: N = 26 [FSH: N = 14, TSG: N = 13]). The FSH or TSG was applied to the ePTFE patch, and then blood flow was restored through the carotid artery. Degree of anticoagulation was assessed by anti-factor Xa activity. The time from restoration of carotid blood flow until achieving hemostasis was recorded. The blood loss from patch suture hole bleeding was measured. Completion intraoperative duplex ultrasound scanning was performed in all cases. Heparin was reversed with protamine sulfate. The primary end point was successful hemostasis within 15 minutes of restoration of carotid blood flow. The secondary end points were the amount of blood loss caused by suture line bleeding and the time to achieve hemostasis.

RESULTS

There was no difference in the number of patients with complete hemostasis at 15 minutes (TSG, 13 of 23; FSH, 12 of 24; P =.77). The measured blood loss was 99.0 +/- 119.9 (SD) mL for TSG, and 105.0 +/- 107.9 mL for FSH (P =.86). The time to hemostasis was the same for both groups (TSG, 16.5 +/- 16.5 minutes; FSH, 16.6 +/- 14.2 minutes; P =.97). Within both treatment groups, the use of larger needles (PT-13) was associated with greater blood loss (FSH, 169.7 +/- 124.2 mL; TSG, 172.7 +/- 151.5 mL) than was the use of smaller needles (PT-9; FSH, 58.8 +/- 66.3 mL; TSG, 34.1 +/- 25.6 mL; P =.036, P =.001, respectively). There were no postoperative strokes or bleeding complications in either group. No abnormalities were shown in either group by means of completion carotid duplex ultrasound scanning.

CONCLUSION

FSH was equivalent, but not superior to, TSG in achieving hemostasis during carotid endarterectomy performed with ePTFE patch angioplasty. Adhesion properties of FSH to ePTFE are possibly different than those to native tissue and warrant additional investigation.

Histopathologic evaluation of an expanded polytetrafluoroethylene-nitinol stent endoprosthesis in canine iliofemoral arteries

PURPOSE

The authors assess a new ePTFE-nitinol stent for its long-term patency, healing, and properties of endothelialization.

MATERIALS AND METHODS

Adult greyhounds (n = 18) underwent bilateral iliofemoral placement of an endoprosthesis (Hemobahn) consisting of a nitinol stent lined with an ultrathin expanded polytetrafluoroethylene (ePTFE) material. Histologic and quantitative morphometric analyses were performed on devices explanted at 2 weeks and 1, 3, 6, and 12 months. The source of endothelialization was examined in four additional devices modified by sealing either the proximal and distal ends or the entire graft with poly(tetrafluoroethylene-co-hexafluoropropylene) (FEP), a nonporous laminate to prevent potential transgraft endothelial cell migration.

RESULTS

Device patency assessed with both intravascular ultrasound and histologic study showed minimal arterial stenosis, irrespective of implant duration. The neointima at less than 3 months consisted of fibrin and inflammatory infiltrate; at later time points, it was composed of mostly smooth muscle cells. Flow surfaces were more than 75% endothelialized by 3 months, which was nearly complete by 6 months. Modified endoprostheses entirely enveloped with FEP resulted in endothelialization of only the proximal and distal ends; the middle regions showed nonocclusive thrombi. Conversely, devices wrapped proximally and distally showed nearly complete endothelialization.

CONCLUSIONS

This ePTFE-nitinol endoprosthesis demonstrated long-term patency at up to 1 year after implantation and showed early and nearly complete endothelialization by 6 months. The design promoted rapid endothelialization of flow surfaces, particularly in the midregion of the device possibly by transgraft migration.

The incidence of heparin-induced antibodies in patients undergoing vascular surgery: a prospective study

PURPOSE

This study prospectively assessed the incidence of heparin-induced antibodies in patients undergoing peripheral vascular surgery and determined whether the incidence is influenced by previous heparin exposure.

METHODS

Fifty-four hospitalized patients (36 men and 18 women) undergoing peripheral vascular surgery and receiving intraoperative heparin anticoagulation were studied. Unfractionated porcine heparin was given for intraoperative anticoagulation and was not continued postoperatively. Carotid endarterectomy was performed in 36 patients, aortic reconstruction in 11 patients, and infrainguinal bypass in 7 patients. Plasma was tested before and after (14 +/- 7.5 [SD] days) surgery for IgG antibodies to the complex of heparin/platelet factor 4, using a standardized, validated enzyme-linked immunosorbent assay (ELISA). Results are expressed as an optical density ratio (ODR) of patient plasma to normal plasma, with the threshold for a positive result of > or = 1.8. Platelet counts and clinical outcomes were also assessed.

RESULTS

The mean patient age was 67.2 +/- 9.7 years. A prior exposure to heparin was documented in 41% of patients. The mean intraoperative heparin dose was 9089 +/- 3607 units. Only 1 patient converted from a negative antibody status to a positive status (1.9%, 95% CI = 0.10%-11.18%). The change in the ELISA ODR after surgery was not significantly different for patients with (+0.042 +/- 0.272) and without (-0.022 +/- 0.299, P = 0.57) prior heparin exposure. Postoperatively, the platelet counts dropped from 227,620 +/- 78,308 microL, to 185,706 +/- 80,842 microL (P < .001). The decrease in platelet count was the same in patients with prior heparin exposure (-23.0 +/- 18.0%) and without (-18.0 +/- 14.0%, P = .46). One thrombotic complication occurred, a femorotibial bypass graft occlusion in a patient who tested negative for antibodies.

CONCLUSION

Heparin-induced antibodies occur infrequently after peripheral vascular surgery. The commonly observed, mild degree of postoperative thrombocytopenia does not appear to be caused by heparin-induced antibodies. These results indicate that a standard dose of heparin for intraoperative anticoagulation during vascular surgery is not associated with a significant risk of heparin-induced thrombocytopenia and thrombosis.

Determination of 60% or greater carotid stenosis: a prospective comparison of magnetic resonance angiography and duplex ultrasound with conventional angiography

The morbidity and cost of conventional angiography (CA) have focused recent efforts in cerebrovascular imaging upon the exclusive use of noninvasive techniques. Our purpose was to prospectively evaluate carotid magnetic resonance angiography (MRA) and to compare its accuracy with color-flow duplex (CFD). Fifty patients were prospectively evaluated with CA and MRA after clinical and CFD findings indicated the need for carotid angiography. CFD measurements of peak systolic velocity (PSV) and end-diastolic velocity (EDV) were made. MRA results were categorized as 0%-39%, 40%-59%, 60%-79%, or 80%-99% stenosis or occluded. Determination of percent carotid stenosis by CA was made as in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Using receiver operating characteristic (ROC) curves, the probability of correctly predicting a > or =60% stenosis using various CFD thresholds and MRA was assessed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in determining > or =60% stenosis were estimated. For MRA the sensitivity was 85% (95% Confidence Interval [CI] = 69%-94%), specificity 70% (CI = 56%-81 %), PPV 68% (CI = 53%-80%), and NPV 86% (CI = 72%-94%). For CFD the sensitivity was 89% (CI = 74%-96%), specificity 93% (CI = 82%-98%), PPV 89% (CI = 74%-96%), and NPV 93% (CI = 82%-98%). When MRA and CFD results were concordant (n = 64), the sensitivity was 100% (CI = 89%-100%), specificity 95% (CI = 81%-99%), PPV 94% (CI = 77%-99%), and the NPV was 100% (CI = 92%-100%). The area under the ROC curve for CFD was 95%, compared to 83% for MRA (p = 0.0005). We conclude that the low specificity of MRA precludes its use as the definitive imaging modality for carotid stenosis. The 93% specificity of CFD alone warrants its consideration as a definitive carotid imaging study. By ROC curve analysis, CFD offers superior accuracy to MRA. Our data support noninvasive preoperative carotid imaging for detecting a threshold stenosis of > or =60% whether CFD is used alone, or in combination with the selective use of MRA.

Primary stenting of atherosclerotic renal artery ostial stenosis

Percutaneous transluminal angioplasty for atherosclerotic ostial lesions of the renal arteries has resulted in high restenosis rates. Recent reports of angioplasty with intravascular stenting show improved results over angioplasty alone. The purpose of this study is to review the results of primary stenting of ostial renal artery stenosis at our institution. Twenty one patients (11 men, 10 women, age 63 +/- 11 years), with atherosclerotic renal artery ostial stenosis in association with hypertension or renal insufficiency underwent renal angioplasty with primary stenting during a 2-year period. Medical records were reviewed for indications, technical success, complications, restenosis, response of hypertension and response of renal insufficiency. A technical success was defined as a normal postprocedure arteriogram with no residual stenosis and no residual gradient. Restenosis was defined as > or =60% diameter reduction identified by arteriography, or duplex scan demonstrating a renal artery to aortic ratio of > or =3.5. Thirty-three stents were placed in 25 arteries with four patients having bilateral procedures. All patients were hypertensive. Nine patients (43%) had chronic renal insufficiency (creatinine > or =1.5 mg/dl). One patient was on hemodialysis. The immediate technical success rate was 95%. Six complications occurred in four patients (two pseudoaneurysms, two dissections requiring additional stents, renal failure, and atheroembolization). Mean arterial blood pressure improved from 117 +/- 13.4 to 103 +/- 12.8 mmHg (p = 0.002) after stenting. Serum creatinine levels decreased from 1.48 +/- 0.57 to 1.31 +/- 0.41 (p = 0.07). Eight patients developed restenosis. The mean follow up was 13 +/- 7 months. Life table analysis showed a cumulative restenosis rate of 65 +/- 18% at 24 months. We advise caution in the application of renal stenting for the treatment of ostial lesions, particularly in patients for whom standard surgical revascularization options are available.

Long-term follow-up of a superficial femoral vein injury: a case report from the Vietnam Vascular Registry

We report a 29-year follow-up of a high-velocity superficial femoral vein injury sustained during the Vietnam War that was treated by emergent ligation. After years of suffering recurrent ulceration from chronic venous insufficiency, this patient underwent axillary vein valve transfer with improvement in his venous hypertension. Long-term follow-up of patients with deep venous injuries is necessary to avoid complications from chronic venous insufficiency.

Presentation and management of venous aneurysms

PURPOSE

Venous aneurysms have been reported to occur in most major veins. These aneurysms may be misdiagnosed as soft tissue masses or as inguinal or femoral hernias. Venous aneurysms of the deep system have been associated with deep venous thrombosis (DVT) and pulmonary embolism (PE). To more precisely characterize these lesions, we reviewed our experience with the disease.

METHODS

A retrospective analysis of our experience over 22 years was performed. The presentation and management of these lesions were reviewed and compared with the literature.

RESULTS

Thirty-nine venous aneurysms were reported in 30 patients. There were 14 men and 16 women. The patients' ages ranged from 3 to 75 years. Thirty aneurysms were located in the lower extremities, four in the upper extremity, and five in the internal jugular vein. Fifty-seven percent of lower extremity aneurysms occurred in the deep system. Patients' symptoms were a mass (75%) associated with pain (67%) and swelling (42%). Thromboembolism occurred in six patients, DVT in three, and PE in three. Eight of nine patients (89%) who had aneurysms of the superficial venous system had their condition misdiagnosed. Diagnosis was made by phlebography (60%), color flow duplex scanning (27%), continuous-wave Doppler scanning (10%), or magnetic resonance imaging (10%). The aneurysm size ranged from 1.7 to 6.0 cm. Management consisted of tangential excision in five (17%), total excision in 23 (77%), and observation in seven (6%).

CONCLUSIONS

Venous aneurysms are unusual vascular malformations that occur equally between the sexes and are seen at any age. Most patients have a painful mass of the extremity, and diagnosis is achieved by radiologic examination. Superficial venous aneurysms of the inguinal region are often misdiagnosed. Thromboembolism is more common in aneurysms involving the deep venous system. Because of their potential morbidity, management should be surgical in the majority of cases.

Saphenous vein versus polytetrafluoroethylene carotid patch angioplasty

BACKGROUND

The optimal material for carotid patch angioplasty after endarterectomy remains uncertain. This study compares the early outcome and recurrent stenosis rates between saphenous vein (SV) and expanded polytetrafluoroethylene (ePTFE) carotid patch angioplasty.

METHODS

The results of 421 consecutive carotid endarterectomies performed over a 72-month period were reviewed. Postoperative complications and restenosis rates, defined as > OR = 60% narrowing measured by color flow duplex, were compared.

RESULTS

Patch angioplasty was performed with SV in 287 and with ePTFE in 110 cases. Patients who had undergone primary closure (n = 20) or whose form of closure was unknown (n = 4) were excluded. The mean age of patients and length of follow-up was similar between groups. Women were more likely to be patched with ePTFE than were men (36% versus 23%, P = 0.02). One death occurred in each group (0.3% SV, 0.9% ePTFE, P = 0.47), and four strokes occurred in each group (1.4% SV, 3.6% ePTFE, P = 0.22). Cervical hematomas requiring operative evacuation occurred in five SV closures and in three ePTFE closures (1.7% versus 2.7%, P = 0.69). Vein harvest site complications occurred in 6 patients (2%) who had undergone SV patch angioplasty. Recurrent stenosis occurred in 3 patients with SV closure and in 3 patients with ePTFE closure (1.0% versus 2.7%, P = 0.35). The 60-month restenosis rates by life table analysis were 2.6% +/- 2.1% for SV and 10.7% +/- 7.9% for ePTFE (P = 0.17).

CONCLUSIONS

The incidence of postoperative complications is similar with SV or ePTFE patch angioplasty; however, vein harvest site complications are avoided with the use of ePTFE. Recurrent stenosis at 5 years occurs infrequently with either SV or ePTFE.

The fate of residual defects following carotid endarterectomy detected by early postoperative duplex ultrasound

BACKGROUND

The purpose of this study is to evaluate the results of color-flow duplex ultrasound (CFD) soon after carotid endarterectomy (CEA) to determine the incidence of residual abnormalities and their effect on subsequent outcome and management.

METHODS

We reviewed 318 consecutive CEAs performed over a 48 month-period. Of these, 206 were followed up with CFD, 195 prior to discharge and 11 at first follow-up (within 9 weeks). Patients (43) followed up with only oculoplethysmography (OPG) or those with no OPG or CFD (69) were excluded from the study. All CEAs were performed under general anesthesia with routine shunting and patch angioplasty.

RESULTS

Twelve of the 206 studies (5.8%) were abnormal. Two patients with an abnormal CFD sustained perioperative stroke, both of whom had distal intimal lesions of > 60% diameter stenosis by velocity criteria. Four patients had > 60% stenosis and were reoperated upon to correct technical errors. The remaining 6 patients are asymptomatic. Four had residual lesions of < 60% stenosis, three of which have returned to normal on subsequent CFD. Two residual lesions had > 60% stenosis; one returned to normal by CFD and the other remains abnormal at 10 months. In the group of 192 normal postoperative CFD studies, there were no strokes, deaths, or redo procedures (0%, 95% confidence interval 0% to 1.54%) compared with a combined 50% rate (6 of 12) of either stroke (2 of 12) or redo procedure (4 of 12) when the postoperative CFD was abnormal (95% confidence interval 22.3% to 77.7%, P < 0.0001). During the study period the CEA stroke rate was 0.9% (3 of 318), with a combined stroke-mortality rate of 1.3% (4 of 318).

CONCLUSIONS

Early postoperative CFD identified residual abnormalities in 5.8% of carotid endarterectomies despite a low overall stroke mortality rate. One half of these abnormalities resulted in stroke or required operative correction. Colorflow duplex ultrasound is useful in identifying residual abnormalities following CEA and should be considered for intraoperative use.

Resistance to activated protein C: a common inherited cause of venous thrombosis

Resistance to activated protein C (RAPC) is a newly recognized hypercoagulable state that was first described in 1993. It has become apparent that RAPC is even more common than deficiencies in protein C, protein S, or antithrombin III (AT-III) and affects an estimated 5% of the general population. The majority of patients with RAPC have an abnormality in factor V (Arg506Gln), which renders factor Va resistant to degradation by activated protein C. Studies in 75 patients referred to the Hematology Laboratory at Walter Reed Army Institute of Research (WRAIR) over a 14-month period for evaluation of venous thromboembolism were reviewed to determine the percentage of those with RAPC. Of the 75 patients in the study, one was deficient in protein S, one was deficient in protein C, and none was deficient in AT-III. In contrast, 27 (36%) patients tested positive for RAPC. Blood was available for DNA analysis in 15 patients with RAPC. Of these 15 patients, nine (60%) tested positive for the Arg506Gln mutation in factor V. Six other patients with RAPC did not have the factor V mutation. Additional risk factors for thrombosis were immobility, obesity, use of oral contraceptives, and pregnancy. The majority of patients had deep venous thrombosis of the lower extremities; 71% had a recurrence if not placed on chronic anticoagulation therapy. Thus RAPC is a significant risk factor for venous thrombosis. Evaluation for inherited hypercoagulable states should include testing for this newly described condition.

Lower extremity lymphedema caused by acquired immune deficiency syndrome-related Kaposi's sarcoma: case report and review of the literature

A case of severe lymphedema of the lower extremity caused by obstruction by human immunodeficiency virus-associated Kaposi's sarcoma is presented. A review of the signs and symptoms of obstructive lymphedema and Kaposi's sarcoma is provided. Early recognition of this clinical entity may allow use of simple preventative measures and help to avoid this life- and limb-threatening situation.

Characteristics of patients at risk for perioperative myocardial infarction after infrainguinal bypass surgery: an exploratory study

Patients requiring infrainguinal bypass surgery often have diffuse atherosclerotic disease, and perioperative myocardial infarction (MI) is a potentially lethal complication that is not uncommon in these patients. To establish additional clinical characteristics that might be useful in identifying patients who require more extensive cardiac evaluation, we conducted an exploratory case-control study comparing 22 patients who had a perioperative MI following elective infrainguinal bypass surgery with 191 control subjects whose bypasses were uneventful. In addition to previously recognized risk factors (e.g., history of angina or prior MI), we examined the association of perioperative MI with (1) results of common preoperative laboratory tests and ECG, (2) preoperative use of certain medications, and (3) intraoperative factors that might be anticipated prior to surgery (e.g., duration of surgery or type of anesthesia). Perioperative MI was associated not only with a history of angina, prior MI, or coronary artery disease but also with the need for certain cardiac medications, higher white blood cell (WBC) counts, ST-segment depression, left bundle branch block, and lengthy surgical procedures. Multiple logistic regression analysis identified the following factors as being independently associated with perioperative MI: preoperative antiarrhythmic agents (odds ratio [OR] = 26.4, p = 0.006), nitrates (OR = 8.4, p = 0.006), calcium channel blockers (OR = 5.5, p = 0.04), and aspirin (OR = 6.8, p < 0.01) and ST-segment depression (OR = 11.8, p = 0.01), WBC count (OR = 1.27/1000, p = 0.005), and duration of surgery (OR = 2.2/hr, p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular dysfunction during infrarenal abdominal aortic aneurysm repair

BACKGROUND

Clinical observations suggest that pulmonary artery occlusion pressure (PAOP) underestimates the resuscitative volumes required prior to release of aortic cross-clamp.

METHODS

To investigate pressure-volume relationships associated with repair of abdominal aortic aneurysm (AAA), we simultaneously monitored PAOP by pulmonary artery catheter (PAC) and estimated left ventricular (LV) diastolic volume using two-dimensional transesophageal echocardiography (TEE) in 22 patients undergoing AAA repair. Data from PAC monitoring and TEE were collected before, during, and after aortic occlusion. TEE cross-sectional images were obtained at the mid-papillary level.

RESULTS

Overall, PAOP correlated with left ventricular end-diastolic area (LVEDA), but the correlation was not particularly strong (r = 0.37, P < 0.0001). Even within individual patients, LVEDA varied widely for a given PAOP. The strength of the correlation between PAOP and LVEDA also appeared to deteriorate during the course of surgery. The best correlation was seen prior to aortic cross-clamping (r = 0.50, P < 0.0001), but fell somewhat during aortic cross-clamping (r = 0.41, P < 0.0001), and even further after unclamping (r = 0.25, P = 0.005).

CONCLUSION

This study demonstrates a relatively weak correlation between PAOP and LVEDA using intraoperative TEE during AAA repair. Furthermore, the strength of the correlation worsened during surgery, particularly after unclamping. Although unclear at this time, this finding may be attributable to changes in LV compliance. We found TEE to be a valuable adjunct in guiding volume resuscitation of patients undergoing AAA repair.

Can air plethysmography accurately identify upper extremity deep venous thrombosis?

PURPOSE

Air plethysmography (APG) is an established, noninvasive means of evaluating lower extremity venous outflow.

METHODS

To determine whether APG could identify deep venous thrombosis (DVT) of the upper extremity, we measured the percentage of venous outflow in the first second (maximum venous outflow [MVO]) of four groups of arms: (1) normal volunteers (no previous central vein catheters), (2) the affected, (3) the unaffected arms of the patients with DVT (proven by venography or duplex scanning), and (4) hospital patients (no previous central vein catheters).

RESULTS

The results of an analysis of variance were as follows: the mean MVO (%) of the affected arms of patients with DVT, 29.4 +/- 2.6, was significantly less than their unaffected arms, 55.3 +/- 3.9, hospital controls, 64.3 +/- 2.2, and normal volunteers, 64.2 +/- 0.9 (p < 0.05). In addition, the unaffected arms differed significantly from all groups (p < 0.05). An MVO of 45% was 2 SD below the mean MVO of the normal volunteer group. Two unaffected arms of the patients with DVT were below 45%, whereas only one affected arm of the patients with DVT was above 45% (45.6%). Therefore a comparison of the distribution of the MVO values revealed virtually no overlap of the affected arms of the patients with DVT with the other three groups.

CONCLUSIONS

We conclude that APG clearly discriminated arms with documented DVT from controls and is a highly accurate means of identifying upper extremity DVT.

Role of arteriography for blunt or penetrating injuries in proximity to major vascular structures: an evolution in management

Over a 14-month period at Boston City Hospital, 93 consecutive patients who had received a blunt or penetrating extremity injury in proximity to a major vascular structure were evaluated. All patients were totally asymptomatic and underwent arteriography for proximity as a sole indication. Twenty-seven patients (27%) were found to have abnormal arteriograms. Muscular branches of the profunda femoris artery were the most frequently injured arteries (28%). Arterial spasm (41%) was the most common radiographic finding. All patients were managed nonoperatively and followed closely by serial pulse examinations. Follow-up arteriography or duplex scanning was used in isolated cases. No patients in this study required operative intervention based on arteriographic findings. No patients have subsequently required operative intervention for delayed arterial abnormalities. Based on these findings we believe the use of arteriography for asymptomatic injuries in proximity to major vascular structures is unwarranted.

The role of air plethysmography in monitoring results of venous surgery

The development of an objective, noninvasive method to assess the hemodynamic effects of venous surgery has long been awaited. Previous methods used to evaluate the results of surgery for varicose veins and venous stasis ulceration have been limited in their quantitative assessment. Now, by use of air plethysmography (APG), we can accurately quantify the effectiveness of corrective venous surgery. Twenty-five extremities that had evidence of venous insufficiency were examined with use of APG before and after venous surgical procedures. Surgery was directed at specific sites of venous incompetence as defined by physical examination and high-resolution duplex imaging. Twenty-one extremities underwent ligation and stripping of the greater saphenous vein. In these patients, APG showed an improvement in venous reflux as demonstrated by a decrease in the venous filling index from 6.6 +/- 0.7 ml/sec to 1.8 +/- 0.3 ml/sec (p = 0.0001) and venous volume from 177.1 +/- 14.5 ml to 139.2 +/- 8.9 ml (p = 0.0008). In addition, these patients showed a mild improvement in calf muscle pump function as noted by an improvement in ejection fraction from 45.8 +/- 2.0% to 50.8% +/- 2.5% (p = 0.07). The residual volume fraction decreased from 45.0% +/- 3.4% to 42.0% +/- 3.7%, a difference that was not statistically significant (p = 0.4). Four extremities with grade III chronic venous insufficiency underwent popliteal vein valve transplantation with use of an autogenous axillary vein valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriography for proximity of injury in penetrating extremity trauma

Arteriography for proximity of injury was studied prospectively at a trauma center. Findings in 85 patients with penetrating extremity wounds were analyzed to determine the prevalence and types of vascular abnormalities seen with these injuries. Ninety-two limb segments were studied for 77 gunshot and 15 stab wounds. Arteriographic findings were positive in 24% overall but in only 5% for injuries confined to major vessels. A 60% positive rate was seen in a small subgroup of 10 patients with fractures due to gunshot wounds. The most frequently injured vessels were muscular branches of the deep femoral artery (59%); the most common injury was focal, non-occlusive spasm (42%). All patients were treated conservatively, without sequelae at follow-up. In this study, the vascular injuries found at arteriography for proximity of injury in penetrating trauma due to bullets of knives, particularly in the thigh, did not require surgical or radiologic intervention.

Traumatic popliteal artery pseudoaneurysms: case report and review of the literature

Traumatic pseudoaneurysms of the popliteal artery are an uncommon late complication of arterial injury. Although reviewed extensively in wartime, they occur less frequently in civilian trauma and have accordingly been less frequently studied. A case report of a traumatic popliteal artery pseudoaneurysm and review of the literature are presented.