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Background To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. Methods A review of our EVA database (1998–2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. Results 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46–018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69–0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. Conclusion Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Purpose: To describe a bailout technique for use during branched/fenestrated thoracoabdominal aortic aneurysm (TAAA) repair to address celiac artery (CA) dissection. Technique: The technique is demonstrated in a 69-year-old man who underwent fenestrated stent-graft repair of a 6-cm type III TAAA. The main fenestrated stent-graft was positioned without difficulty, and the renal and superior mesenteric arteries were stented. A stent-graft was placed in the CA, but angiography showed the vessel to be occluded by dissection beyond the stent-graft. Wire manipulations to regain access to the true lumen culminated in perforation. At this point, the gastroduodenal artery was catheterized with a 0.035-inch guidewire, which was advanced in retrograde fashion into the CA true lumen and then snared back to the left brachial artery forming a loop. After exchange for a 0.014-inch system, self-expanding stents were deployed into the hepatic artery. Postoperative recovery was uneventful, and the patient was discharged on day 6. At 1-year follow-up, the patient was doing very well. Imaging demonstrated no endoleak, no graft migration, and sac shrinkage to a diameter of 5.1 cm. Conclusion: The “loop technique” can be a very useful and effective bailout maneuver in regaining access to the true lumen of a dissected CA in patients undergoing branched/fenestrated thoracoabdominal aortic aneurysm repair.

Background Klippel–Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy. Methods The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan–Meier method and Log-rank statistics were used where appropriate. Results Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7–55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P Conclusions In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome.

Hybrid approaches for repair of aneurysms involving the ascending aorta and the aortic arch have been developed to avoid or reduce duration of cardiopulmonary bypass and circulatory arrest and to decrease operative time, blood loss, hospital stay, morbidity, and mortality. These include ascending aorta-based debranching or cervical extra-anatomical bypasses followed by stent-grafting. In patients with associated descending aortic aneurysms, the elephant trunk technique is used followed by stent-grafting of the descending thoracic aorta. A review of the literature of hybrid aortic arch reconstructions, published over past 7 years, reveals perioperative mortalities from 0% to 13%, stroke from 0% to 10%, and spinal cord injury in 0% to 13%. The outcomes are comparable to contemporary results from total open and total endovascular reconstructions in spite of the fact that the hybrid approach is generally taken in patients with high surgical risk for open repair and with prohibitive anatomy for total endovascular repair.

Recently published evidence-based guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) include recommendations for evaluation, classification, outcome assessment and therapy of patients with varicose veins and more advanced chronic venous insufficiency (CVI). The need for such guidelines has been evident since imaging techniques and minimally invasive technologies have progressed by leaps and bounds and radiofrequency ablation, laser and sclerotherapy have largely replaced classical open surgery of saphenous stripping. This report reviews the most important guidelines recommended by the SVS/AVF Venous Guideline Committee. It is obvious, however, that some of the technology that is recommended in North America is either not available or not affordable in some parts of the world for patients with varicose veins and CVI. The readers are urged therefore to also consult the guidelines of their national societies, recent publications of the National Institute for Clinical Excellence and the Venous Forum of the Royal Society of Medicine. Venous specialists should also keep in mind that scientific evidence should always be combined with the physician's clinical experience and the patient's preference when the best treatment is selected for an individual patient.

Vascular malformations occur as a result of an arrest in the development of the vascular system. The modified Hamburg classification distinguishes arterial, venous, arteriovenous, capillary, lymphatic, and mixed vascular malformations. Each malformation is further subdivided based on anatomy and on the time when arrest in development of the embryogenesis occurred; malformations can be truncular or extratruncular. Progress in the last decade in management has been significant because of improvements in open surgical procedures and perfection of percutaneous and hybrid endovascular interventions and devices, such as balloons, stents, and stent-grafts. There has been increasing use of embolization for the treatment of malformations with coils, other particles, glue, or with endovascular placement of occlusive plugs. Absolute alcohol, detergent liquids, or foam have been used for sclerotherapy with improved efficacy. The agents are delivered percutaneously or through a catheter placed either into the feeding arteries or the draining veins. This review aims to aid vascular and endovascular specialists in staying familiar with vascular malformations. These specialists need to be able to evaluate the patients, perform treatment if appropriate, or refer complex cases to multidisciplinary vascular malformation clinics and vascular centers.

The traditional approach for open reconstruction of the obstructed subclavian vein has been through disarticulation or partial removal of the clavicle. Partial or full sternotomy has been used for innominate vein or superior vena cava reconstructions. Each approach has its inherent limitations with regard to optimal exposure and may be associated with morbidity. Herein we report the case of a 33-year-old man with chronic central venous occlusion, who underwent a right axillary-superior vena cava bypass using the femoral vein via partial sternotomy with infraclavicular resection of the first rib. Early, minor revision of the graft was required, but the patient had a successful clinical outcome 1 year after surgery. Techniques, advantages, and pitfalls of such reconstructions are discussed in this case report.

Between 1986 and 2005, 22 patients (mean age, 14.7 years; range, 3-21) with renal hypertension underwent renal artery revascularization for 28 lesions, 23 with open repair (OR) and 5 with percutaneous transluminal renal angioplasty (PTRA). Thirty-day morbidity was 17% (4/23). Hypertension was cured in 13 (57%), improved in 8 (38%), and unchanged in 1 (5%). Renal function worsened in 1. At a mean follow-up of 4.9 years, 1-year patency rate was 94% and maintained for 5 years. Hypertension at 1 year was cured in 6 of 14 patients (43%; OR, 4; PTRA, 2) and improved in 8 (57%; OR, 7; PTRA, 1); hypertension at 5 years was cured in 50% and improved in 50%. Renal function remained unchanged in all patients who were followed. The authors conclude that both OR and PTRA benefit pediatric patients. PTRA for selected patients may be promising as a first line treatment or as a bridge to definitive OR in children with small arteries.

Klippel-Trenaunay syndrome (KTS) is a rare, sporadic, complex malformation characterized by the clinical triad of (1) capillary malformations (port wine stain); (2) soft tissue and bone hypertrophy or, occasionally, hypotrophy of usually one lower limb; and (3) atypical, mostly lateral varicosity. KTS is a mixed vascular malformation, with predominant capillary, venous and lymphatic components, without significant arteriovenous shunting. Management is largely conservative and the extent of diagnostic evaluation is determined by the planned treatment. Compression is the hallmark of conservative management; laser can be used to treat port wine stains. Imaging before vascular interventions must confirm venous anatomy and deep venous drainage. Techniques for ablation of superficial veins and malformations are individualized and may include sclerotherapy with alcohol or foam, endovenous thermal ablation or, as used most frequently in our practice, surgical stripping and phlebectomy. Intraoperative use of tourniquet will decrease bleeding, selective use of an inferior vena cava filter will prevent pulmonary embolism. A multidisciplinary approach to management of KTS is warranted.

Celiac artery syndrome exists, although it remains controversial, and in some patients a firm diagnosis cannot be established. Duplex scanning or computed tomographic, magnetic resonance, or contrast aortography will confirm intermittent or permanent compression of the celiac artery by the crus of the diaphragm, the median arcuate ligament, or fibrous ganglionic tissue. Preoperative ganglion block and exercise gastric tonometry are useful diagnostic tools to predict better outcome after treatment. In patients with well-defined syndrome of chronic mesenteric and gastric ischemia or with exercise-induced pain, good results can be expected with division of the median arcuate ligament with open celiac artery reconstruction. Patients with atypical pain or history of psychiatric disorders only occasionally benefit from surgical repair. The role of primary stenting of celiac artery compression is still not well defined, and current data do not support the use of balloon-expandable stents. Laparoscopic division of the median arcuate ligament followed by celiac artery stenting is an effective, minimally invasive technique to manage selected patients with celiac artery compression syndrome.

Neurofibromatosis type 1, also called von Recklinghausen's disease, is an autosomal dominant disorder linked to chromosome 17, characterized by growth impairment of the neural crest cells (ectoderm) manifested by multiple neural tumors, cutaneous pigmentations, and Lisch nodules. Disease phenotype develops with time, making its penetrance almost complete by 5 years of age. Compression of the gastro-intestinal, urinary, or pulmonary tracts by visceral neurofibromas may generate serious complications. Neurofibromatosis type 1 is remarkable for its association with occlusive (stenoses) or aneurysmal arterial disease affecting predominantly the renal arteries and less often the abdominal aorta (middle aortic syndrome), and mesenteric and peripheral arteries. Appraisal of existing literature reveals that timely vascular intervention by way of conventional surgery and/or endovascular therapy may provide patients with effective and durable treatment. The far greater propensity for malignant connective/soft-tissue neoplasms and vascular disease in neurofibromatosis type 1, amid potential complications from the gastro-intestinal, urinary, and pulmonary tracts, leads to a significantly increased morbidity and decreased life expectancy. Neurofibromatosis type 1, from presentation and diagnosis to its treatment, is reviewed, with emphasis on vascular disease and its management with open vascular surgery and endovascular therapy.

Middle aortic syndrome (MAS) is a clinical condition generated by segmental narrowing of the abdominal or distal descending thoracic aorta. MAS may be acquired, caused by Takayasu's or temporal arteritis (giant cell arteritides), neurofibromatosis, fibromuscular dysplasia, retroperitoneal fibrosis, mucopolysaccharidosis, and the Williams syndrome, or congenital, ascribed to a developmental anomaly in the fusion and maturation of the paired embryonic dorsal aortas. Segmental aortic stenosis may be located at the suprarenal, inter-renal or infrarenal aorta, with a high propensity for concomitant stenoses in both the renal (63%) and visceral (33%) arteries. Hypertension proximal to the aortic stenosis, and relative hypotension distal to it, are characteristic findings in MAS. Typical manifestations include headache, early fatigue on exertion, and bilateral lower-limb claudication. The severity of hypertension is the primary indication for intervention and the factor determining procedural timing. As a great proportion of patients with MAS are children or teenagers, the clinical benefits of early surgical intervention to reverse refractory hypertension have to be weighed against the repercussions pertaining to the insult of surgery on the developing aorta. Open surgery is the primary treatment of tubular aortic narrowing (MAS) associated with renovascular hypertension and visceral artery stenosis. This entails aortoaortic bypass of the diseased segment or, less often, patch aortoplasty and usually bypass grafting of the stenosed renal and visceral arteries performed with autologous conduits, particularly in the youngest of patients. Endovascular therapy may provide a sound minimally invasive treatment in MAS caused by discrete aortic stenoses that do not encompass the mesenteric and renal arteries. Hypertension is thus improved or cured in more than 70% of patients. Prognosis after uncompromised surgical reconstruction is rewarding in the mid and long term in patients with congenital aortic coarctation but deteriorates in patients with aortoarteritis and recurrent inflammatory activity.

Carotid body tumors (CBT) are rare and usually benign neoplasms (60%-90%), originating from the mesoderm and neural ectoderm. In view of the extensive and unrelenting growth of unresected CBT, encasing vital neurovascular structures, and the significant incidence of malignancy (or = 10%), surgical excision is the standard treatment of choice. Despite progress in CBT imaging and surgical technique, cranial nerve deficit, stroke, and death continue to affect 10% to 40% of patients undergoing curative surgical resection, particularly in large tumors proximal to the skull base. In such cases, CBT shrinkage by preoperative embolization, improved surgical access utilizing mandibular subluxation, and electroencephalographic monitoring combined with meticulous surgical technique may enable curative tumor resection, without prohibitive morbidity. In light of associated disability, preoperative acknowledgment of the ever-present substantial risk of cranial nerve injury cannot be overemphasized. We report on a patient with a large symptomatic CBT treated surgically with the aid of mandibular subluxation and preoperative embolization.

We present a 59-year-old woman who underwent femoropopliteal bypass to relieve claudication caused by superficial femoral artery occlusion. We performed endoscopic saphenous vein harvest and used minimal access approaches to the anastomoses to reduce the risk of postoperative wound complications and speed recovery. The technique of the minimal access operation is described and we discuss the pertinent literature outlining results of endoscopic saphenous vein harvest used for infrainguinal bypass procedures. With the improvement in technology, reduction in wound complication rates, and decrease in overall expense, we predict that minimal access approaches for infrainguinal bypass procedures will regain popularity among vascular surgeons.

Advances in diagnosis and in endovascular and surgical treatments of both acute and chronic venous diseases have focused attention on several, previously clinically less important, details of venous anatomy. The time has come to standardize venous nomenclature so that general practitioners and specialists in the United States and abroad speak the same language. There is a need to adopt a universal terminology for the saphenous veins, to avoid the myriad of eponyms of perforators and, most importantly, to omit once and for all, the term “superficial” femoral vein when talking about a deep vein of the thigh. New anatomic names, such as the saphenous fascia and saphenous subcompartment, have to gain better recognition. To achieve the desired consensus on venous nomenclature, an international meeting was held in Rome, Italy, in 2001, under the auspices of the International Union of Phlebology. In this review on venous anatomy, we describe the most important previously published clinical recommendations from this conference, and suggest modifications based on their clinical experience using the new terminology.

Partial or complete coverage of the renal arteries by the stent-graft during endovascular abdominal aortic aneurysm repair is a serious problem. We present two cases with this complication; both were successfully managed using renal artery stents. To minimize the risk of renal artery coverage, completion aortography with good visualization of the renal arteries is recommended. Even a slight increase in serum creatinine after endovascular abdominal aortic aneurysm repair can be a sign of renal artery coverage due to early proximal migration or misplacement during deployment. Computed tomographic scan with and without intravenous contrast is recommended to establish the right diagnosis. Early stenting of the renal arteries is usually possible and associated with an excellent prognosis.

Flash pulmonary edema can occur in the face of renal artery stenosis. Although there is a growing trend toward the treatment of renal artery stenosis with percutaneous techniques, this is not feasible in the case of a heavily calcified nearly occluded aorta. In this report, we describe the case of a 76-year-old woman with severe renal, mesenteric, and iliac atherosclerosis. We performed a staged vascular reconstruction by initially placing an axillary-femoral-femoral bypass to unload a severely compromised left ventricle in preparation for aortic clamping for a visceral and renal artery bypass. This type of staged repair may be useful in aortic reconstruction for patients with severely compromised left ventricular ejection fraction.

The evolution of vascular surgery toward minimally invasive approaches appears to be inevitable. Thus, innovative and reliable minimally invasive anastomosis techniques are needed to facilitate minimally invasive vascular surgery. Current endovascular anastomosis techniques are limited by their reliance on suitable arteries for access and attachment. Their dependency on the fate of the arterial attachment sites is greater than for the conventionally sutured anastomosis. These limitations will be difficult to over come. Videoscopic anastomosis techniques may offer both the advantages of endovascular surgery in terms of rapid postoperative recovery and reliability of open-sutured anastomosis. With improved training and instrumentation, such as robots, semiautomatic or automatic anastomotic devices, the video scopic approaches will likely become technically easier. The chief disadvan tage of current open-sutured anastomoses is the invasive exposure required, elevated morbidity and mortality, and associated p...

Open surgical or endovascular revascularization of the lower extremity is not always successful. Early and intermediate-term failures of vascular grafts, stents, and stent grafts occur due to technical mistakes, thrombosis, or intimal hyperplasia. The outcome of lower extremity revascularization can be improved by adjuvant antithrombotic treatment (antiplatelet drugs, anticoagulation) and by antiproliferative therapy such as drugs, brachytherapy, or gene therapy. Adjuvant drug therapy can be systemic (oral or parenteral) or local (direct injection or placement of drug-eluting grafts or stents). Systemic drug therapy may carry the additional benefit of preventing cardiovascular events, such as stroke or myocardial infarction. Unfortunately, it can also be associated with serious, mainly hemorrhagic, adverse effects. We review the English-language literature of antithrombotic and antiproliferative adjuvant therapies in the prevention of early and intermediate failures following lower extremity revascularizations.

Embolization during carotid reconstruction is the most frequent cause of neurologic complications. Atraumatic surgical technique, intraoperative monitoring of the cerebral circulation and completion imaging all contribute to reduce the risks of embolization. Data from the literature suggest that the incidence of perioperative neurologic events correlate with the number of microemboli demonstrated by transcranial Doppler. Cerebral protection for percutaneous angioplasty with stenting of the carotid artery needs to be introduced, since without protection devices endovascular techniques are associated with > 8 times the rate of microemboli seen during carotid endarterectomy.

The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1,1990. and January 1,1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients (2%) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.

Objective: To review the techniques and results of surgical treatment of the superficial and perforating veins in patients with chronic venous insufficiency. Methods: The current techniques used at the Mayo Clinic for treatment of simple varicose veins and venous ulcers are presented. Results of subfascial endoscopic perforator vein surgery (SEPS) are discussed and data from large centres are tabulated. Results are compared with those reported following non-operative management. Synthesis: High ligation and invagination stripping of the incompetent segment of the saphenous vein, with stab avulsion of branch varicosities, is the optimal surgical technique to ablate superficial venous incompetence. SEPS is safer than open perforator vein ligation and is the technique of choice to interrupt incompetent perforating veins. A review of 12 series on SEPS, that included 361 limbs, found an ulcer recurrence rate of 10% in those 211 patients who underwent ablation of superficial reflux together with SEPS. One hundred and fifty limbs had SEPS alone, without saphenous stripping: ulcer recurrence in this group at a mean of 23 months was 12%. Results in primary valvular incompetence were significantly better than in post-thrombotic syndrome. Conclusions: Ablation of superficial reflux remains the main surgical treatment of all forms of chronic venous insufficiency. SEPS is safe and effective to interrupt medial calf perforators and results in rapid ulcer healing and low recurrence in patients with primary valvular incompetence. The treatment of post-thrombotic syndrome remains a challenge. Results of the North American Venous Ulcer Surgery (NAVUS) trial, a prospective, randomised, multicentre study, will be required to provide level 1 evidence of the effectiveness of surgical treatment over medical therapy in the treatment of venous ulcers.

Elastic compression is the primary treatment modality of venous ulcers. Local ulcer treatment is important to enhance granulation and prevent or treat infection, while surgical treatment is aimed at correcting the underlying venous stasis and ambulatory venous hypertension. This debate reviews the pros and cons of surgical treatment for venous incompetence and discusses current evidence to support the use of subfascial endoscopic perforator vein surgery (SEPS). Ablation of superficial reflux with high ligation and stripping of the incompetent saphenous vein, done together with avulsion of varicose veins, remains the main surgical treatment of chronic venous insufficiency. Level 1 evidence of clinical and hemodynamic improvement directly related to interruption of incompetent perforators is currently not available. The North American SEPS registry experience and reports from larger centers, however, provide data on rapid ulcer healing, low morbidity, and decreased wound complications from endoscopic perfor...

The coexistence of urologic malignancy (UM) and abdominal aortic aneurysm (AAA) is rare. Simultaneous treatment may increase morbidity, whereas staged operations delay necessary treatment. We reviewed our experience to develop guidelines for evaluation and management. Clinical data of all patients diagnosed between 1980 and 1998 with both AAA and UM, who also had staged or simultaneous surgical treatment were reviewed. Four thousand forty-seven patients underwent AAA repair during the study period at our institution. Of these, 18 (0.44%) patients, 16 men and two women (mean age: 74 years, range: 61 to 92) had UM. UM was discovered incidentally in nine patients with AAA with computed tomography (CT) scan (7) and ultrasonography (2). In one patient with AAA, hematuria raised the suspicion of UM. Eight patients were diagnosed with AAA during evaluation of UM by CT scan or ultrasound (7) or during laparotomy (1). Initial signs and symptoms included abdominal pain (33%), gross hematuria (33%), and urinary tract infections (17%), although 33% were asymptomatic. The AAA was symptomatic at first examination in three (17%) patients, 14 (78%) patients had hypertension, and two (11%) had renal insufficiency (overall mean serum creatinine: 1.6, range: 0.8 to 3.7). Mean AAA diameter was 5.8 cm (range: 3.8 to 8 cm). Aortography documented significant contralateral renal artery disease in two patients. Twelve patients underwent simultaneous AAA repair and resection of UM; the operations were staged in six (AAA repair first in 2, nephrectomy first in 4). One patient required emergent repair of a ruptured AAA three days after nephrectomy. UM was treated with nephrectomy in 17 patients, and with bilateral ureterectomy and cystectomy in one. A straight aortic graft was implanted in seven patients, a bifurcated graft in ten, and one had extra-anatomic reconstruction. Two patients required reconstruction of the contralateral renal artery. The 30-day mortality rate was 0% after staged and 6% after simultaneous repair (p= >0.1). Major perioperative complications occurred more frequently after simultaneous (42%) than after staged repair (33%), although the difference was not significant (p= >0.1). Two patients developed postoperative renal failure. Seventeen patients were followed for an average of 3.9 years (14 days to 10.8 years). Three (17%) patients died of recurrent cancer at 1, 10.7, and 10.8 years after surgery. Patients with resectable UM have satisfactory long-term survival, which justifies aggressive treatment of concomitant AAA. Aortography in these patients is suggested to exclude contralateral renal artery disease. Complications were frequent, but simultaneous repair did not increase morbidity or mortality significantly. The risk of AAA rupture after nephrectomy, need to correct contralateral renal artery disease at the time of nephrectomy, and disadvantage of delaying treatment of UM are compelling reasons to favor simultaneous treatment of AAA and UM.

Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive technique performed in patients with advanced chronic venous insufficiency. The objective of the operation is to interrupt incompetent medial calf perforating veins to decrease venous reflux and reduce ambulatory venous hypertension in critical areas above the ankle where venous ulcers most frequently develop. Patients with stasis skin changes and healed or active venous ulcerations are potential candidates for the operation. Preoperative evaluation is performed with duplex scanning of the superficial, deep and perforator system, to diagnose both obstruction and valvular incompetence. Results of the North American SEPS Registry (NASEPS) as well as experience in several individual centers confirmed that the operation has significantly fewer wound complications than the classic open surgical techniques, and that rapid ulcer healing can be achieved. At the Mayo Clinic an ulcer recurrence rate of 12% was observed, with recurrence significantly more frequent in post-thrombotic limbs than in patients with primary venous valvular incompetence. The NASEPS Registry report confirmed a 2-year cumulative ulcer recurrence rate of 28%; ulcer recurrence was significantly more frequent in post-thrombotic limbs, especially in those with deep venous obstruction. SEPS is a new, low-risk, outpatient procedure that effectively decreases perforator reflux in patients with venous ulcerations, and should be added to our armamentarium to treat patients with advanced chronic venous disease. Long-term prospective and randomized studies are, however, still required to provide level I evidence of late efficacy.

The diagnosis and treatment of large abdominal arteriovenous fistulae continue to be challenging, since presentation is frequently atypical and the patients are usually severely ill.Clinical suspicion of rupture of an aortic or iliac aneurysm into the iliac vein or vena cava is confirmed in a hemodynamically stable patient by computed tomography, performed with intravenous contrast. Expeditious open surgical repair is recommended. Intraoperative techniques are directed to avoid embolization of aneurysmal debris through the fistula, to decrease blood loss using rapid cell saver, and the use of Swan Ganz catheter to optimize major hemodynamic alterations. Although complications are frequent, clinical outcome is more favorable than retroperitoneal or intraperitoneal rupture of an aortic aneurysm. Endovascular repair of primary aortocaval fistula remains a task for the future.

A review of the embryology and anatomy of the blood supply to the spinal cord is presented. The main artery supplying the anterior cord is the great radicular artery (often referred to by the eponym "the artery of Adamkiewicz"). This artery usually originates from the left side of the aorta, most frequently between the ninth thoracic and first lumbar levels to supply blood to the anterior spinal artery However, variations in the origin of the artery are common. Blood supply to the spinal cord can be compromised during descending thoracic or thoracoabdominal aortic reconstructions, performed for aneurysmal disease or for aortic dissection. This may lead to devastating neurological complications, most notably paraplegia. Although the etiology of paraplegia is multifactorial, a relatively small artery plays an important role in the development of serious neurological complications.

Medical and surgical emergencies occasionally present as ruptured abdominal aortic aneurysms (RAAA). To assess benefits of laparotomies and adverse effects of unnecessary operations, the authors reviewed their experience. Thirteen patients, 9 women, 4 men (mean age: 72 years, range: 41-85) underwent emergency laparotomy between 1988 and 1996 for presumed RAAA and were found to have other surgical or medical emergencies. All the patients presented with hypotension, 12 had abdominal or back pain, four had pulsatile abdominal mass. Rupture was not excluded by computed tomography scan in three or by ultrasonography in two patients. Laparotomy disclosed intact abdominal aorta in all, but seven patients had abdominal aortic aneurysm. Of five surgical emergencies, laparotomy was indicated in four: three for ruptured visceral artery aneurysms, one for perforated duodenal ulcer. The fifth patient required thoracotomy for ruptured thoracic aneurysm. Four of eight medical emergencies were myocardial infarctions. One iatro genic complication required reoperation for bleeding. Mean hospital stay was 18 days; mean hospital charges were $40,771. Seven (54%) early deaths occurred; none were caused directly by the operation. Laparotomy was indicated in one third of deceptive emergencies that present as RAAA. Although mortality, morbidity, and costs were high, iatrogenic surgical complica tions were rare and deaths were not caused by unnecessary operations.

Increased shear, pressure, and oxygen tension in vein grafts may alter production of endothelium-derived vasoactive and anti-mitogenic factors such as nitric oxide which subsequently affect development of neointimal hyperplasia. This study was designed to determine whether or not nitric oxide mediates endothelium-dependent responses in femoral in situ vein grafts. Non-reversed, canine femoral vein grafts were placed bilaterally to bypass a ligated segment of the femoral artery in dogs. After 6 weeks, the grafts were removed, cut into rings, and suspended in organ chambers for measurement of isometric force. In some rings the endothelium was removed deliberately. In the presence of indomethacin, the synthetic analog of l -arginine, l -NG-monomethyl-arginine (10−4 M; l -NMMA) did not cause a significant change in baseline tension of rings with endothelium. l -NMMA reduced only contractions of rings with endothelium to the alpha-adrenergic agonist UK 14,304. The analog also reduced maximal relaxations to the calcium-ionophore, A23187 in rings with endothelium. In addition, l -NMMA reduced relaxations of rings without endothelium to adenosine diphosphate by 35%. Positive immunostaining for nitric oxide synthase was present in both the myointima and media of histological sections of grafts. In conclusion, these results suggest that in situ vein grafts exhibit two unique properties which are unlike unoperated arteries or veins: (i) alpha2-adrenergic receptors may be coupled to the release of contractile endothelium-derived factors associated with production of nitric oxide; and (ii) nitric oxide may be released by the smooth muscle in response to purinergic stimulation. The presence of nitric oxide synthase throughout the wall of the graft may result in production of nitric oxide in response to adenosine diphosphate released by platelets and to circulating catecholamines. © 1997 The International Society for Cardiovascular Surgery.

Successful replacements of the superior vena cava (SVC) using autogenous saphenous or superficial femoral vein or prosthetic grafts have been previously performed, but the use of allograft for treatment of SVC syndrome has not been reported. The patient treated by the authors was a forty-one-year-old woman who presented with severe venous congestion of the head and neck caused by fibrosing mediastinitis. In addition, she had sclerosing cholangitis and chronic liver failure. To treat her SVC syndrome and provide access for fluid and blood transfusion and for possible venovenous bypass, SVC reconstruction was performed concomitant to orthotopic liver transplantation. A left innominate vein-right atrial bypass was inserted using an iliocaval allograft. The patient had an uncomplicated recovery, and at six months after surgery her SVC allograft is widely patent and her transplanted liver is functioning well. The venous allograft is an excellent conduit for those patients who are receiving immunosuppression therapy to avoid rejection of a transplanted organ.

Between 1978 and 1990, 32 patients (15 men and 17 women; mean age 48 (range 15–83) years) underwent 35 operations for renal artery aneurysm (4.2% of 829 renal artery repairs). Eleven patients presented with acute symptoms (nine with hematuria, eight with abdominal pain, two with acute hypertension). Twenty-eight of the 32 patients had chronic hypertension. The diagnosis was confirmed by angiography in all but two. The mean diameter of the renal artery aneurysm was 1.7 (range 0.7–9.0) cm. Seventeen patients had concomitant renal artery stenosis; none of the aneurysms ruptured. Nephrectomy was performed in seven patients and excision of the aneurysm without reconstruction in five. Twenty patients underwent 23 reconstructions using lateral suture (three procedures), vein patch (three), saphenous vein (13), Dacron (three) or composite (vein and hypogastric artery) graft (one). Seven patients underwent ex vivo renal artery repair. There was no perioperative death or secondary nephrectomy. One postoperative graft occlusion was successfully revised. Hypertension improved in 50% of patients. The presence of hypertension, enlargement of a renal artery aneurysm, solitary kidney, bilateral involvement, acute hematuria or potential loss of kidney or renal function may be indications for surgical treatment of an aneurysm > 1.5 cm in diameter. A renal artery aneurysm of any size should be repaired in women who may become pregnant. Where there is branch involvement, ex vivo repair is the procedure of choice for renal salvage.