Vascular and Endovascular Surgery

The authors present a retrospective survey of 58 patients who had carotid subclavian bypass operations for “subclavian steal.” Further examination of 43 of the patients after an interval of up to 8 years revealed that in most the steal persisted despite a patent bypass. The authors present a hypothesis based on matched impedances that provides a logical explanation for these observations.

When expanded polytetrafluoroethylene (PTFE) is used for hemodialysis access, the authors' initial preference is a forearm loop arteriovenous (AV) graft below the antecubital fossa. However, AV graft thrombosis remains a significant problem caused mainly by venous outflow hyperplasia and managed often by either surgical or radiologic thrombectomy and angioplasty. At the time of surgical revision, the lack of an adequate superficial or deep forearm outflow vein below the elbow would require an antecubital (across the elbow) jump bypass revision to a more proximal upper arm vein to salvage the original forearm AV graft. With an increasing interest in monitoring the specific outcomes of the different surgical interventions used to salvage thrombosed hemoaccess, the authors reviewed their most recent 24--month experience of 32 antecubital jump revisions using ring reinforced PTFE. The mean primary patency of these antecubital jump revisions was 8.2 months with 18 presently patent. AV grafts revisions using antecubital jump grafts confer additional patency; they are another important method for salvaging thrombosed AV hemodialysis grafts.

The purpose of this study was to present the long-term results of our experience, which includes thrombolysis, surgical decompression, and long-term anticoagulation. The medical records of 24 patients who were admitted to Academic Hospital Vrije Universiteit, Amsterdam, the Netherlands, between January 1983 and October 1997, with effort thrombosis of the subclavian vein were reviewed. There were 21 men and 3 women, with a mean age of 30.5 years and an average duration of the symptoms of 2.9 days. Clinical diagnosis was confirmed by phlebography and duplex in all patients. A loading dose of 10,000 units streptokinase was given followed by an infusion at a rate of 10,000 units per hour. Phlebography was repeated daily in order to evaluate the effect of the treatment. Thrombolysis was achieved in 2 to 8 days (mean 5 days). After achievement of complete thrombolysis, anticoagulation with heparin and coumarin derivatives was started; the latter were continued for 3 months.

Six to 12 weeks after the thrombolysis, patients with costoclavicular compression syndrome underwent surgery. A transaxillary first rib resection, partial scalenotomy, and transection of the tendon of subclavian muscle were performed. Thrombolysis was achieved in all patients but one, with a successful lysis percentage of 95.8%. In one patient, the local streptokinase therapy had to be discontinued because of pulmonary embolism. Resection of the first rib was performed on 19 patients. Two patients refused to be operated on. The other three were lost to follow-up, right after the thrombolytic therapy. In long-term evaluation, all the patients who underwent first rib resection were symptom free, whereas the two patients who refused to be operated on had pain and discoloration of the affected arm, although venous patency was achieved.

The subclavian vein thrombosis occurs as a result of repetitive trauma due to anatomic constriction of the vein by the clavicle and the first rib complex. Therefore, we advise addressing the therapy not only to the superimposed thrombus but also to the correction of the underlying anatomic abnormality.

Juxtarenal aortic aneurysm (JRAA) is an unusual, but not rare, pattern of aneurysmal disease of the abdominal aorta in which dilatation extends up to, but does not involve, the renal arteries. The objective of this report was to retrospectively analyze experience with JRAA repair at a tertiary referral center over a 5-year period. From November 1990 through December 1995, 12 consecutive patients underwent repair of JRAA by a single surgeon. There were six men and six women, ranging in age from 65 to 82 years (mean = 77 +2 years). All patients underwent preoperative imaging by aortography, ultrasound, or computed transaxial tomographic (CTT) scanning. Mean aneurysm diameter was 6.6 ± 0.3 cm. Three of the aneurysms were ruptured; however, the rupture was contained within the retroperitoneum and hemodynamic stability was maintained. Eleven aneurysms were approached transperitoneally and one retroperitoneally. Aortic clamping was at the suprarenal level in seven instances and at the supraceliac level in five instances. The left renal vein was divided to facilitate exposure in three instances. Warm renal ischemia time was 27 ± 2 minutes. Eight straight and four bifurcation grafts were placed. All patients survived 30 days. Preoperative creatinine was 1.2 ± 0.1 mg/dL. Creatinine peaked on postoperative day 4 at 1.6 ± 0.2 mg/dL and was 1.5 ± 0.3 mg/dL on postoperative day 10. In no instance was temporary dialysis necessary in the postoperative period, nor did chronic renal failure occur. Postoperative CTT scanning in one patient presenting with a ruptured JRAA revealed an infarcted and nonfunctioning left kidney. In the three patients in whom the left renal vein was divided, mean creatinine was 1.1 ± 0.1 mg/dL preoperatively and 0.9 ± 0.2 mg/dL at discharge. JRAA repair can be safely performed by aortic clamping at the suprarenal and supraceliac level. These maneuvers are well tolerated and provide the exposure necessary to facilitate aortic anastomosis at the juxtarenal level.

A new method of preserving the kidney during reconstruction of renal arteries is presented. This method of continuously perfusing the kidney with normothermic, autologous blood flow from a radial artery is very simple and provides enough time to reconstruct renal arteries even for inexperienced surgeons.

The routine use of arteriography and duplex scan in arterial trauma has improved the diagnosis of asymptomatic arterial lesions. Specifically, in cases of blunt arterial lesions, intimal flap is the most frequent type of occult arterial trauma and usually follows an arterial contusion. Treatment of traumatic intimal lesions is controversial owing to its unknown natural history. Current therapeutic options include arterial reconstruction and clinical observation. The development of angioplasty catheters and stents has opened a new venue for the treatment of intimal flaps. The goal of this study was to evaluate the efficacy of endoprosthesis in the prevention of arterial thrombosis following traumatic intimal flap.

The study was performed on 12 female mongrel dogs weighing more than 15 kg each. The common (CF) and superficial (SF) femoral arteries were exposed from the inguinal region to the midportion of the thigh in both posterior limbs. The SF was first crushed with a hemostatic forceps to induce a severe arterial contusion. A longitudinal arteriotomy of 2 cm was performed distal to the clamp site. A 5 mm deep intimal flap was than created along the 2 cm segment. The arterial wall was than sutured with prolene 7-0. The same procedure was performed on both SF. One of the arteries was randomized to receive a Palmaz Stent while the other was kept untreated for control. After 3 weeks, palpation, ultrasound Doppler and macroscopic studies were performed on both arteries to determine whether the arterial lumen was occluded or not. All arteries treated with stents were patent after 3 weeks, while five of the 12 untreated arteries were occluded (p < 0.05).

Large intimal flaps are potentially thrombogenic. The use of stents is a good alternative in this situation, preventing arterial thrombosis, in the first 3 weeks after the trauma.

Daflon 500 mg has been shown to have beneficial effects on microcirculatory disturbances causing tissue hypoxia in chronic venous insufficiency (CVI). To assess the effects of Daflon 500 mg on venous disorder in the lower extremity by means of dorsal pedal venous oximetry measurements, a 4-week prospective study was carried out in 33 patients having a mild or moderate stage of CVI in one leg. In treatment with Daflon 500 mg at a daily dose of two tablets, there were significant (p>0.05) increases in partial pressure of oxygen (Po₂), oxygen saturation (So₂) and pH, and a decrease in partial carbon dioxide pressure (Pco₂). Clinical findings attributable to CVI were markedly improved. Comparison of dorsal pedal venous, oximetry parameters in the symptomatic leg and the clinically unaffected other leg was made before and after 4 weeks of oral therapy. Significant (p>0.05) differences were observed between involved and healthy lower limbs.

The polyepoxy compound is a new cross-linking agent that is now replacing glutaraldehyde, and human ureter is a new potential substitute for small-caliber arterial prostheses. The present study was performed to compare the use of human ureter grafts tanned with a polyepoxy compound, human ureter grafts tanned with glutaraldehyde, and human saphenous vein grafts tanned with a polyepoxy compound for small-diameter arterial substitutions. Human ureter grafts tanned with a polyepoxy compound (n= eight), human ureter grafts tanned with glutaraldehyde (n=six), and human saphenous vein grafts tanned with a polyepoxy compound (n=eight) were implanted in the carotid arteries of Japanese white rabbits. These grafts were sacrificed after either 1 month's or 6 months' observation. There was no evidence of rejection, aneurysmal formation, and/or infection. Human ureter gcafts tanned with a polyepoxy compound after 1 month's observation (n=six) showed excellent patency without stenosis at the anastomotic sites as well as function, and the histologic findings revealed monolayer endothelial-like cells covering the surface of the graft. Human ureter grafts tanned with glutaraldehyde after 1 month's observation (n=six) were completely occluded with severe intimal hyperplasia. Human saphenous vein grafts tanned with a polyepoxy compound after 1 month's observation (n= six) were patent at the time of explantation, but moderate stenosis caused by intimal hyperplasia at the anastomotic sites was observed. The preliminary data also suggest that, with longer observation of up to 6 months, human ureter grafts tanned with a polyepoxy compound (n=two) showed excellent patency. However, a longer observation of up to 6 months for human saphenous vein grafts tanned with a polyepoxy compound (n=two) revealed severe intimal hyperplasia with intramural thrombosis and/or severe calcification. This study suggests that human ureter grafts tanned with a polyepoxy compound could serve as more satisfactory bioprostheses for the reconstruction of smallcaliber vessels than human ureter grafts tanned with glutaraldehyde or human saphenous vein grafts tanned with a polyepoxy compound.

Knowledge of the normal and abnormal anatomy of the inferior vena cava and its branches increases the ease and effectiveness of the surgical treatment of occlusions and aneurysms of the aortoiliac segment.

The surgical anatomy and techniques for dealing with renal vein anomalies, vena cava duplication, transpositions and arteriovenous fistulas are presented; these aids to the early recognition of venous abnormalities simplify appropriate dissection and forestall inadvertent hemorrhage and vascular injury.

The authors discuss a rare case of massive atheroembolization to the lower extremities occurring in a golfer after a relatively minor low-impact accident. Delayed presentation led to major limb loss.

The authors report an intravascular treatment in the case of posttraumatic pseudoaneurysm of a stenotic internal carotid artery, using a stent graft.

A 53-year-old woman with deep venous thrombosis who was receiving IV heparin developed a large retroperitoneal hematoma, which compressed the femoral nerve. Symptoms of femoral neuropathy were present and an abdominal computed tomography scan confirmed the diagnosis. The development of retroperitoneal hematomas following heparin IV use is rare; however, physicians must be aware of this complication, which may determine definitive neurologic deficits.

Vascular rings are congenital lesions that cause tracheobronchial and esophageal symptoms as a result of compression of these structures. The majority of cases are recognized in infancy, childhood, and occasionally adolescence. Rarely, vascular rings first present in adulthood. The authors present the case of a vascular ring in an elderly woman who complained of dysphagia.