Vascular and Endovascular Surgery

Hypertension is intricately entwined in vascular pathology and morbidity and uncontrolled blood pressure is a leading cause of cardiovascular mortality. Unfortunately, many patients will present to the vascular surgeon with uncontrolled blood pressure elevation and yet, although vascular surgeons have been involved in treating the renovascular etiology, they seldom become actively involved in the medical management of hypertension. However, positive reinforcement by the vascular surgeon about the benefits of blood pressure control may significantly impact the patient's willingness to comply with medications. Some of these medications may also have secondary benefits such as reducing the incidence of diabetes. Accordingly modern vascular surgeons, who want to do more for their patients, need to have a basic understanding of hypertension and its treatment. This manuscript provides an overview of the modern definitions and treatment methods for primary hypertension that should provide the vascular surgeon with sufficient information to play an active role in the management of this co-morbid condition.

Background:There has been increasing recognition of the detrimental effect of peripheral arterial disease (PAD) on the health of Americans, and yet there is no common national program of public PAD education designed to diminish this effect.

Format:To heighten awareness of this problem, a 2-day PAD Public Education Strategy Meeting was recently attended by representatives of 17 professional societies and public health associations whose missions support the prevention, diagnosis, treatment, and rehabilitation of vascular diseases. This Public Education Strategy Meeting was intended to provide the rationale and structure to create a national PAD public awareness campaign to diminish the health effect of PAD and to improve cardiovascular outcomes in the United States. This document (1) provides the rationale for creation of a national PAD public education program; (2) reviews the development and success of national hypertension, hypercholesterolemia, and Women's Heart Health public education programs as models of educational efficacy; (3) elucidates how the work of many vascular professionals has led to a national consensus for creation of a national PAD public educational program; (4) provides an overview of the National Heart, Lung, and Blood Institute PAD education meeting; and (5) outlines the “next steps” required to accomplish these goals.

Outcome:This meeting achieved consensus that we share responsibility for developing accurate, unified messages to promote PAD awareness and improved care. Participants agreed that the creation of such messages should be linked to plans to disseminate them to all Americans at risk. A consensus was reached that such messages, when commonly created and offered to the public, are most likely to achieve the rewards in better health that all Americans deserve. The Vascular Disease Foundation, a not-for-profit foundation whose mission includes public education about the prevention, diagnosis, treatment, and rehabilitation of PAD, will devote its resources to guide a new coalition in this process and to create a national PAD awareness campaign. During 2003 and 2004, the coalition will create the organizational underpinnings and time line for what will undoubtedly be a multiyear effort.

Conclusion:Participants of the Public Education Strategy Meeting agreed to create a broad coalition to develop a National PAD Public Awareness Program, with the objectives to develop and disseminate public education messages on PAD. A successful national PAD education program will contribute to creation of a broader mandate to improve global cardiovascular health in the United States.

Peripheral arterial disease (PAD) is an underdiagnosed circulatory problem in the primary care setting. Individuals are at increased risk for cardiovascular disease; therefore, there is the need for a technique capable of early identification and detection of patients with PAD. The focus of this study was to compare the accuracy of a new operator-independent method of measuring ankle brachial index (ABI) with the traditional Doppler ultrasound method of determining ABI. In 246 limbs the authors compared ankle systolic pressures and ABI measured by a new automated oscillatory method called the ABIgram with those measured by standard Doppler ultrasound. In phase 1, the 2 methods for measuring ankle systolic pressure had a mean difference of 2 mm Hg with a standard deviation of 6.7 mm Hg. In phase 2 the mean difference was 3.1 mm Hg with a standard deviation of 5.1 mm Hg. Further, ABI as measured by the 2 methods fell within 1% and demonstrated a 5% error in reproducibility. These numbers pass the SP-10 standard for medical devices established by the FDA. The ABIgram module of the Vasocor ®Vascular Diagnostic Center offers primary care physicians the ability to rapidly obtain ABI measurements comparable to the standard technique. Further, the ABIgram may be operated by staff commonly found in the primary care setting.

Gastrointestinal complications are known to occur after open elective aortic aneurysm repair. This leads to increased morbidity, mortality, length of stay, and hospital costs. The authors hypothesize a change in the character and/or frequency of early postoperative gastrointestinal complications after endovascular aneurysm repair as compared to open abdominal aortic repair. This is a retrospective cohort study in which the medical records of 153 consecutive patients who underwent endovascular infrarenal aneurysm repair from November 1998 to August 2001 were reviewed for gastrointestinal complications. Of these 153 patients, 9 (5.9%) had postoperative gastrointestinal complications. Three patients (1.9%) underwent exploratory laparotomy for small bowel obstruction. One patient had had a right hemicolectomy for cancer 2 years before stent graft placement. This patient needed a partial small bowel resection. One patient had had a right hemicolectomy 4 months before stent graft placement; he had lysis of adhesions with no bowel resection. A third patient underwent operative repair of an incarcerated inguinal hernia. Six patients (3.9%) had paralytic ileus that was treated by nasogastric tube or observation resulting in an extended hospital length of stay. All cases of ileus resolved without any operative intervention. No patients in this series developed any intestinal ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding. After endovascular aneurysm repair, gastrointestinal complications such as ileus and postoperative small bowel obstruction are seen with a similar frequency as after open aortic repair. This occurs despite the absence of a laparotomy with mesenteric dissection and evisceration. In this series, these complications are associated with longer hospital length of stay but no increased mortality rate. No instances of colonic ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding were seen in this series.

To evaluate the outcome of patients with renal insufficiency undergoing endovascular repair of abdominal aortic aneurysm (AAA), data were prospectively collected between 1998 and 2003 on patients undergoing elective repair of their AAA with a stent graft. The patients were divided into 2 groups: those with serum creatinine (Crs) concentrations <1.2 (Group A) and those with Crs = 1.2 mg/dL not requiring hemodialysis (Group B). The outcomes of the procedure for these 2 groups were compared. Different variables that existed between the 2 groups and contributed to mortality included estimated blood loss (EBL), volume of contrast used in the operating room, incidence of diabetes (DM), tobacco use, and history of myocardial infarction (MI). In total, 213 patients underwent elective repair of their AAA with use of a stent graft: 61% who had a Crs <1.2 mg/dL (Group A) and 39% who had a Crs =1.2 mg/dL not requiring dialysis (Group B). Among 129 patients with normal renal function there was an 18.6% complication rate and 1.6% mortality rate. Of 83 patients with renal insufficiency not on hemodialysis 30.1% (Fisher's Exact Test = 0.076) had 1 or more complications and there was a 6% (Fisher's Exact Test = 0.166) mortality rate. One patient in Group A (0.8%) progressed to hemodialysis and 5 (6%) patients in Group B progressed to end-stage renal disease requiring hemodialysis (p=0.068). A statistically significant higher proportion of the patients in Group B had a history of MI (p<0.001). There was no difference in the amount of EBL between the 2 groups, but a significantly lower amount of contrast (p<0.05) was used in patients with renal insufficiency.

The purpose of these authors' study was to analyze their center's experience with orthotopic heart transplantation (OHT) and abdominal aortic aneurysms (AAA) with particular attention to corticosteroid dosing, hemodynamic parameters, and aneurysm growth rate. A retrospective review of all patients (453) who underwent OHT at their university-affiliated medical center over an 18-year period (1981–1999) was undertaken. Nine (2%) patients who developed AAAs were identified and aneurysm growth was correlated with corticosteroid immunosuppression and hemodynamic parameters. The mean age of OHT patients was 44.5 ±15 years and the majority were males (371 males, 82%). Median follow-up was 5.7 years. Ischemic cardiomyopathy (IC) was the most common indication for transplantation (45.5% of patients). All AAA patients were male (p= 0.157), with a mean age of 58.4 ±4.8 years (p= 0.001), and had undergone OHT for IC (p= 0.001). Mean arterial blood pressure and ejection fraction in the AAA patients had increased from pretransplant values of 107 mm Hg and 14.3 ±5.7% to 142 mm Hg (p=0.017) and 54.1 ±14.1% (p<0.001), respectively, before aneurysm repair. Mean aneurysm diameter at the time of repair was 6.0 ±0.8 cm, and the average growth rate was 1.2 ±0.4 cm/year in the 4 patients in whom it could be measured. Aneurysm repair was performed urgently in 2 patients and electively in 7 patients with 1 early postoperative death (11%). The extent of corticosteroid immunosuppression, corticosteroid pulses, and total corticosteroid dosing did not correlate with the rate of aneurysm growth. Improved hemodynamics and progressive posttransplant hypertension may contribute to aneurysm formation and growth in this group of patients.

Erectile dysfunction (ED) is a common complication after aortoiliac surgery. The aims of this study were to determine the incidence of ED in patients with aortoiliac occlusive disease or aneurysm and evaluate the effect of revascularization by means of open surgery or iliac angioplasty/stenting upon erectile function by using the new International Index of Erectile Function (IIEF) questionnaire. All male patients who had previously undergone open aortoiliac reconstruction or iliac angioplasty/stenting and who were alive at the time of this study were first contacted by telephone. Those who agreed to take part in the study were sent anonymous IIEF questionnaires. Patients were asked to recall their sexual function before and 3 months after the procedure. ED was defined as IIEF score of <11. After telephone interview, a total of 116 patients agreed to take part in the study. The response rate was 61%. Two patients, one in each group, had ED preoperatively. The preoperative IIEF scores were no different in surgery and angioplasty/stenting groups (p=0.3). Overall, 46/63 patients reported worsening erectile function postoperatively. In the surgery group (n=37), 32 patients reported deterioration of their sexual function, 3 no change, and 2 improvement, while in the angioplasty/stenting group (n=26), 14 patients had deterioration, 11 no change, and 1 improvement. In both groups, the IIEF score decreased significantly postintervention; however, the deterioration was much more pronounced after open surgery (p<0.001). Of the 61 patients with “normal” erectile function (IIEF= 11), 10 patients (28%) developed ED following surgery, but none after angioplasty/ stenting (p=0.003). As judged by the IIEF, a significant proportion of patients undergoing open and endovascular procedures experience worsening sexual function.

Endovenous occlusion of the greater saphenous vein with radiofrequency (RF) energy has been shown to be a safe and effective treatment for saphenofemoral reflux. Operating parameters initially developed for the VNUS ®Closure ®system were selected in order to provide sufficient energy to controllably and transmurally heat the vein wall to cause collagen contraction and destruction of the vein wall while limiting the degree of perivascular heating. Procedural advances, such as ultrasound-guided tumescent infiltration along the course of the vein to be treated, have provided an added level of thermal protection to the perivenous tissue during the application of RF energy. The purpose of this study was to evaluate the effect of raising the setpoint temperature from 85°C to 90°C while doubling the pullback speed from 3 to 6 cm/minute on vein adventitial temperature. An in vitro simulation of a peripheral vein surrounded by body tissue was created by fixing freshly excised bovine veins in beefsteak kept moist by normal saline. A VNUS RF generator, in conjunction with a VNUS Closure catheter, delivered temperature-controlled RF energy to the bovine vein intima. Adventitial temperatures were recorded as the catheter was withdrawn and peak temperatures from 4 treatment groups were analyzed. The mean peak adventitial temperatures for the groups in which the adventitia was lightly bathed in saline were 64.4°C and 64.9°C with a setpoint temperature of 85°C at a pullback speed of 3 cm/minute and 90°C at a pullback speed of 6 cm/minute, respectively. The mean peak adventitial temperatures for the groups in which the adventitia was bathed in a 2.0 mm layer of saline were 51.3°C and 47.7°C with a setpoint temperature of 85°C at a pullback speed of 3 cm/minute and 90°C at a pullback speed of 6 cm/minute, respectively. Temperature-controlled radiofrequency occlusion of the saphenous vein, performed using an intimal setpoint temperature of 90°C and double the pullback speed of the historical VNUS Closure treatment (6 vs 3 cm/minute), produced comparable temperatures at the adventitial surface in an in vitro model. The addition of a 2.0 mm layer of saline significantly reduced the peak adventitial temperatures.

Axillary artery injury from blunt trauma to the shoulder is uncommon. Fracture of the neck of the humerus is a rare cause of injury to the axillary artery. Four cases of axillary artery thrombosis from humeral neck fracture are reported. Each of the first 2 patients presented with a pulseless and acutely ischemic limb after a trivial fall. A repair of the axillary artery with saphenous vein interposition graft was performed in the first patient. The extremity was salvaged, but a residual radial and ulnar neurologic deficit persisted. The second patient presented with a pulseless insensate upper extremity accompanied by motor loss. He underwent primary axillary artery repair. Still early in his postoperative course, he has had global brachial plexopathy and is undergoing intensive physical therapy. The third patient had a delayed presentation of brachial plexopathy and sympathetic reflex dystrophy. Arterial reconstruction was not required owing to excellent collateralization. The fourth patient presented with a cool pulseless extremity. His recovery is nearly complete after bypass of the axillary artery with a reversed saphenous vein graft. In addition, a review of the literature revealed 24 cases of axillary artery injury associated with humeral neck fracture. The mean age was 66.6 years. The most common mechanism of injury was a fall (79%). Thirteen patients (46%) presented with a neurologic deficit. Acute ischemia was present in 68%. Physical examination predicted the arterial injury in all but 1 patient. The injured axillary artery was repaired in 26 cases. Revascularization by an interposition graft was the most common procedure. All grafts and reanastomoses were patent and led to limb salvage. Of 9 primary repairs, 3 amputations were performed. Although limb salvage rate was 89%, a good functional outcome was obtained in only half of the patients. A high index of suspicion is required for early diagnosis of axillary artery injury. Despite excellent results of vascular reconstruction, the outcome remains determined by the excessive neurologic morbidity. Recognition of the associated brachial plexus injury is essential to improve the functional outcome of this unusual arterial injury.

Carotid body tumors are rare neoplasms, which typically present as a slow growing, painless neck mass found along the anterior border of the sternocleidomastoid muscle. These tumors are generally benign but possess aggressive local growth potential. Therefore, definitive treatment requires surgical resection. The authors describe a case of a patient with a carotid body tumor and review the most recent literature on this unusual topic.

Formation of an artery-to-ureter fistula (AUF) is a rare event caused by pelvic surgery or ureteral instrumentation. This presentation details the unique occurrence and treatment of simultaneous bilateral iliac artery-to-ureter fistulae. A 55-year-old man developed significant arterial hemorrhage during ureteral stent removal initially from the right and, subsequently, from the left side. Following expedient ureteral balloon tamponade, endovascular management via femoral approach with vein-covered stents was successful for each fistula without adverse long-term effects. Endoluminal therapy using autologous tissue-covered stents represents a simple, yet durable, treatment option in these challenging cases.