Vascular and Endovascular Surgery

The objective of this paper is to evaluate treatment of primary venous insufficiency by endovenous saphenous vein obliteration. Three hundred one limbs were treated in 206 women and 67 men with a mean CEAP Clinical Class of 2.4 ±0.9. Endovenous obliteration was combined with high ligation in 67 limbs (22%) and with stab avulsion phlebectomies in 181 (60%). Acute occlusion was achieved in 290 limbs (96%). Obliteration failures in 11 limbs were treated by saphenous stripping or managed expectantly. Paresthesias followed 15% of treatments confined to the thigh and upper leg and affected 30% of limbs when treatment extended to the ankle (p < 0.001). Eight potentially preventable thermal skin injuries occurred, five in particularly superficial venous segments, of which four were in men. At a mean follow-up of 4.9 months, 21 (7.2%) of successfully treated veins have partially or totally (n = two) recanalized, but only 11 (3.8% of 290) have Doppler-detectable reflux. Ninety-one patients have been followed up for 6 months to 1 year, showing significant improvement in CEAP class and progressive relief from clinical symptoms. At their latest visit, 94% rated themselves as being symptom-free or substantially improved. These midterm results with endovenous obliteration in the treatment of primary varicose veins suggest that it may be as effective as surgical stripping in eliminating greater saphenous vein reflux and delaying the appearance of new varicose veins. Simple procedural modifications, such as not treating to the ankle, prophylactic infiltration about superficially placed veins, and early duplex surveillance should diminish the complications observed in this early experience.

Ureteral obstructions following aortoiliac or aortofemoral bypass grafting for aortoiliac occlusive and aneurysmal disease are infrequently reported. Ureteral obstructions can be self-limiting and resolve without further treatment or can signify a more serious underlying complication such as graft infection or a pseudoaneurysm formation. The authors present a series of five patients with ureteral obstruction secondary to aortobifemoral bypass grafting. Different treatment options are described and an algorithm for the management of these complications is presented.

The objective of this study was to evaluate the immediate efficacy and long-term results of a standard protocol of percutaneous, low dose, intraarterial streptokinase treatment in acute arterial thrombosis. This involved analysis of 48 consecutive patients with acute peripheral arterial thrombosis, treated with thrombolysis between October 1988 and August 1997. There were 30 men and 18 women patients, with an average age of 66.5 years. There was thrombosis of the native artery in 32, thrombosis of an aneurysm in seven, and graft occlusion in nine. After the occlusion was defined by arteriography, the low-dose streptokinase (10,000 units per hour) was continuously infused into the thrombosed segment following a bolus injection of 10,000 units. The initial success rate (defined as partial or complete lysis) was 79.6%. Additional therapy after lysis consisted of percutaneous transluminal angioplasty in 18, bypass surgery in six, anticoagulant therapy in seven, and amputation in seven owing to irreversible ischemic damage. One patient died of myocardial infarction before additional therapy. Of the 20.4% failures to fibrinolysis, two patients received bypass surgery, two surgical thrombectomy, three sympathectomy, and three had amputations. Local bleeding complications were seen in five (10%) patients. Only one patient needed surgical exploration. Allergic reaction to streptokinase was seen in five patients (10%) and fibrinolytic therapy was continued with urokinase in three. In the follow-up (1-107 months) eight patients died and three amputations were performed after a mean time of 17 months after thrombolysis owing to progression of arteriosclerosis. This resulted in a limb salvage rate of 76% after 1 year and 65% after 5 years (Kaplan-Meier).

Low-dose, local, intraarterial streptokinase therapy is an effective preliminary step in management of acute arterial thrombosis. Especially with adequate additional treatment, it is possible to achieve satisfactory long-term patency rates.

Purpose. Noninvasive methods of studying the microcirculation have been advocated in patients with advanced peripheral vascular disease to assess skin viability. Good reliability is a prerequisite for such parameters. This study was carried out to evaluate the variability of three methods: transcutaneous oxygen tension measurement (tc.pO9, diode laser Doppler fluxmetry (dLDF), and capillary microscopy (CM).

Methods. Repeated measurements were performed in 20 patients with restpain or severe disabling intermittent claudication (ankle/brachial pressure index <0.5). Tc.pO₂ was performed on the dorsum of the foot and measured under baseline conditions, during 4 minutes of O₂-inhalation, and during reperfusion after 3 minutes of tourniquet occlusion. dLDF was performed on the palmar skin of the hallux, at rest, and during reperfusion after 3 minutes of tourniquet occlusion. CM was performed at the nailfold of the hallux; capillary density, morphologic changes of the capillaries, and perfusion with fluorescein were studied.

Results. Increased tc.pO₂ rates during the oxygen inhalation and reperfusion tests are well-reproducible and show discriminative power. Resting tc.pO₂ seems less valuable. Some dLDF parameters are highly reproducible, but only resting flux and the flux increase rate during reperfusion demonstrate discriminative power. CM is highly reproducible as performed by one observer. The capillary morphology score allows for severity grading.

Conclusion. Controversies on interpretation and cutoff values of microcirculatory parameters could well be associated with the variability of some of the parameters. Only parameters with adequate reproducibility and discriminatory power can be used to evaluate intervention procedures or to determine amputation levels.

Dipyridamole sestamibi nuclear scanning (MIBI) is a commonly used test to screen for cardiac disease in patients undergoing elective abdominal aortic aneurysm (AAA) surgery. However, its routine use for all patients is controversial. The purpose of this study was to determine whether MIBI scanning could identify high-risk patients and lead to decreased myocardial infarction (MI) and cardiac death when compared with patients who did not receive MIBI scanning preoperatively. The authors reviewed 212 consecutive patients undergoing elective AAA repair between January 1990 and December 1993. Data regarding preoperative cardiac status, MIBI scan results, and cardiovascular outcomes were collected. During this period, 92 patients had MIBI scans preoperatively while 120 patients underwent AAA surgery without MIBI scanning. The average ages for these two groups were 70 ±8 and 71 ±9 years, respectively. The frequency of coronary artery disease, angina, and previous MI in the MIBI group was 47%, 26%, and 29%, respectively. In the non-MIBI group, these frequencies were 39%, 23%, and 28%, respectively. Eleven patients were identified in the MIBI group to have moderate or large reversible defects. Of these, five underwent cardiac revascularization with no morbidity. The frequency of postoperative MI and death for the MIBI group was 1.1% (1/92) and 0%, respectively. In the non-MIBI group, it was 3.3% (4/120) and 1.7% (2/120), respectively (p=0.54). Preoperative MIBI scanning identified high-risk patients for AAA surgery. Following coronary revascularization for these high-risk patients, the overall MI and mortality rates were similar to those in patients who did not receive MIBI preoperatively.

A 59-year-old competitive ballroom dancer presented with right thigh claudication upon strenuous exercise. Following a diagnostic arteriogram, she underwent aortoiliac reconstruction for an ulcerated and narrowed distal aorta and severely stenotic right common iliac artery. The procedure was complicated by acute graft thrombosis due to a heparininduced “white-clot” syndrome. Several passes were made with Fogarty balloon catheters through each iliac limb and from the femoral arteries down each lower extremity until normal pulses returned. The patient returned 3 months later with a 6-week history of severe disabling bilateral calf claudication. An arteriogram showed diffusely narrowed iliac, femoral, and popliteal arteries, bilaterally, compared to the generous caliber vessels seen 3 months earlier. A diagnosis of myointimal hyperplasia secondary to Fogarty balloon catheter injury was made.

Lower extremity claudication most commonly results from atherosclerotic disease. Cystic adventitial disease of the popliteal artery is a rare entity that also manifests with symptoms of claudication. The disease usually occurs in otherwise healthy men without cardiovascular risk factors for atherosclerosis. Extrinsic compression of the arterial lumen leads to arterial insufficiency in these patients. A fairly typical case of cystic adventitial disease of the popliteal artery is reported and a review of the literature is presented.

Finding a suitable conduit for lower extremity arterial bypass can be a challenge, especially when the greater saphenous vein has been used for other bypasses. Several different types of conduits have been tried with variable success rates. Autologous vein grafts seem to have a higher patency rate than prosthetic grafts. In this article, a case is presented in which a continuous loop of basilic-cephalic vein was used to bypass superficial femoral artery to dorsalis pedis. This innovative conduit has the advantage of being autologous and without any intervening venovenous anastomoses and its associated complications. A review of such vein loop grafts and other types of conduits is presented in the text.

This is a case of a 67-year-old woman with a congenital arteriovenous fistula of the right upper extremity arising from the right subclavian artery. It was treated successfully with catheter-directed embolization techniques. In reviewing the literature, a high incidence of right-sided congenital arteriovenous malformations of the proximal upper extremity was identified. This high incidence may be related to the complexity of the embryologic development of the right subclavian artery.

A 47-year-old woman presented with a 2-year history of severe proximal claudication symptoms in both legs. Digital subtraction aortography (DSA) showed a localized occlusion of the infrarenal abdominal aorta. A longitudinal arteriotomy and an endarterectomy of the aorta were performed. The arteriotomy was closed with a polytetrafluoroethylene (PTFE) patch. Postoperatively, the follow-up demonstrated a normal aorta with all pedal pulses palpable. In patients with the above symptoms, middle aortic syndrome should be included in the differential diagnosis.

Free flap transfer is a technically feasible adjunct to wound healing in tissue loss in vascular reconstructive surgery. The authors present the case of a 68-year-old diabetic who underwent successful femorodistal bypass and free flap transfer on both of his legs with successful bilateral limb salvage at 25 and 17 months, respectively.