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Background: Flush occlusions of the superficial femoral artery (SFA) often preclude endovascular interventions for femoral-popliteal lesions. Furthermore, some investigators have found poor results with angioplasty and stenting or stent-grafting of such lesions. For suitable patients with TransAtlantic Inter-Society Consensus (TASC) C and D femoral-popliteal lesions involving a flush occlusion of the SFA, we have adopted a technique to manage this disease pattern by combining femoral endarterectomy through a single, small groin incision with distal superficial femoral-popliteal stent-grafting. In this article we have described our technique and results in 14 consecutive patients., Methods: A total of 14 patients who underwent this hybrid procedure between May 2005 and April 2009 were identified from our prospectively gathered registry. Data on indications, complications, length of hospital stay, pre- and postoperative ankle-brachial indices, patency determined by duplex ultrasonography, limb salvage rates, and functional results were collected., Results: Of the 14 patients, nine were operated on for disabling claudication, two for rest pain, and three for tissue loss; three fit TASC C criteria and the remaining 11 fit TASC D. In all, 12 patients had stent-grafts placed and two had bare-metal stents inserted. The median ankle-brachial index of the affected leg was 0.61 (range, 0.23-1.71) before surgery and 0.99 (range, 0.63-1.39) after surgery (p = 0.034). There were no significant complications associated with the procedure. One patient died secondary to unrelated causes 5 months later, two did not return for follow-up after discharge, and three were lost to follow-up after primary patency was confirmed at 2, 4, and 4 months, respectively. Of the remaining eight patients, four still have primary patency of their stent-grafts at 52, 19, 17, and 4 months, respectively, and a fifth patient has secondary patency at 24 months. The remaining three patients occluded their stent-grafts with primary patency last confirmed at 0.5, 2.5, and 8 months, respectively; two have stable claudication and one has a nonhealing wound and rest pain, but all have limb salvage to date., Conclusion: Combined femoral endarterectomy and endovascular femoral-popliteal stent-grafting provides a viable option for revascularization of flush SFA occlusions with only a minimal groin incision. The technique described in this article allows for a larger number of patients with flush SFA occlusions to be treated primarily with endovascular techniques and helps avoid a traditional common femoral to above-the-knee popliteal prosthetic bypass., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Objective: We analyzed our results with percutaneous rotational atherectomy catheters and specifically examined whether they were more likely to be associated with a successful outcome when used to treat smaller diameter vessels such as infrapopliteal (IP) arteries compared to larger diameter femoropopliteal (FP) arteries and infrainguinal arterial autogenous vein grafts (GRAFTS). Material and Methods: Between January 1, 2005, and December 31, 2006, athrectomies were performed on 32 patients for claudication (14), gangrene (9), rest pain (4), and failing GRAFTS (5). Treated vessels included 14 superficial femoral, 1 popliteal, 5 anterior tibial, 4 posterior tibial, and 3 peroneal arteries along with 5 failingGRAFTS. All procedures were performed by vascular surgeons in an endovascular operating suite using a mobile C-arm. Results for larger diameter vessels including FP arteries and GRAFTS were combined (FP + BYPASSES) and compared to results of IP artery lesions. Follow-up averaged 10 weeks (range, 0.5-34 weeks). Results: Length of treated lesions averaged 4.2 cm (range, 1-15 cm) for FP + GRAFT lesions (9 occlusions, 11 stenoses) versus 1.8 cm (1-4 cm) for IP lesions (6 occlusions, 6 stenoses; P ¼ ns). Procedural success rate based on postoperative segmental pressures, pulse volume recordings, and duplex ultrasound was 70% (14/20) for FP + GRAFTS versus 83% (10/12) for IP lesions (P ¼ .03). Need for concomitant adjunctive balloon angioplasty to treat residual stenosis tended to be higher for FP + GRAFT lesions (40% [8/20]) compared to IP lesions (25% [3/12]; P ¼ ns). During follow-up, 25% (5/20) of FP + GRAFTS lesions required reintervention (3 balloon angioplasties, 1 thrombectomy, 1 GRAFT pseudoaneurysm) versus none for the IP lesions (P ¼ .03). Limb salvage rates were 90% (18/20) for FP + GRAFT lesions versus 100% (12/12) for IP lesions during this short follow-up. Conclusions: These preliminary results suggest that short segment IP arterial stenoses and occlusions can be successfully treated with atherectomy catheters with a lower rate of reintervention during short-term follow-up, less need for concomitant adjunctive balloon angioplasty and a lower complication rate compared to FP + graft lesions. [ABSTRACT FROM AUTHOR]

Objective: Stenosis of the cephalad internal carotid artery (ICA) can present a challenge, making it difficult to obtain a technically satisfying distal end point during endarterectomy. Surgical revision of distal defects can be difficult and yield unsatisfactory results. The purpose of this review is to evaluate the efficacy of intraoperative carotid stenting as an adjunct to endarterectomy to salvage technical defects identified at the cephalad ICA endarterectomy site. Methods: Between January 2001 and February 2008, 14 patients were found to have technical defects located at the cephalad ICA endarterectomy site on intraoperative completion arteriogram. All defects were treated with adjunctive carotid stenting. Patient age ranged from 53 to 84 years (mean, 69 years). Indications for surgery were asymptomatic stenosis (nine), amaurosis fugax (two), and cerebrovascular accident (three). Operative time ranged from 2 to 5 hours (mean, 2.5 hours). Cervical block was used in all but two patients who received general anesthesia. Results: Technically satisfying results with stenting were achieved in all 14 patients. One patient suffered a perioperative transient ischemic attack; however, neurologic symptoms were noted before placement of the stent in this patient. There were no stent-related complications. All stents remained patent on duplex follow-up averaging 18 months. Conclusion: Intraoperative salvage carotid stenting is an effective and safe adjunct to endarterectomy when unsatisfactory technical defects are identified at the cephalad ICA endarterectomy site. [Copyright &y& Elsevier]

Intraoperative completion studies of the internal carotid artery following carotid endarterectomy are recommended to ensure technical perfection of the repair. Transit time ultrasound flowmeter does not require trained technicians, requires less time than other completion studies such as duplex ultrasonography and contrast arteriography, and is noninvasive. Flowmetry was compared with duplex ultrasonography and contrast arteriography to determine if the relatively simpler flowmetry could replace these two more widely accepted completion studies in the intraoperative assessment of carotid endarterectomy. Comparative intraoperative assessment was performed in 116 carotid endarterectomies using all three techniques between December 1, 2000 and November 30, 2003. Eversion endarterectomy was performed in 51 cases and standard endarterectomy with prosthetic patching in 65 cases. Patients underwent completion flowmetry, duplex ultrasonography, and contrast arteriography studies of the exposed arteries, which were performed by vascular fellows or senior surgical residents under direct supervision of board-certified vascular surgeons. Duplex ultrasonography surveillance was performed 1 and 6 months postoperatively and annually thereafter. Mean follow-up was 18 months (range, 6–42 months). The combined ipsilateral stroke and death rate was 0%. The mean internal carotid artery flow using flowmetry was 249 mL/min (range, 60–750 mL/min). Five (4.3%) patients had flow < 100 mL/min as measured with flowmetry, but completion contrast arteriography and duplex ultrasonography were normal and none of the arteries were re-explored. One carotid endarterectomy was re-explored based on completion duplex ultrasonography that showed markedly elevated internal carotid artery peak systolic velocity (>500 cm/sec); however, exploration was normal and completion flowmetry and contrast arteriography were normal. Duplex ultrasonography studies revealed internal carotid artery peak systolic velocities > 150 cm/sec in 15 patients, but flowmetry and contrast arteriography were normal in all 15 cases and none of the arteries were re-explored. There was no correlation between flow rates measured using flowmetry and peak systolic velocities measured using duplex ultrasonography One abnormal contrast arteriogram showed an intimal flap that was revised, but duplex ultrasonography and flowmetry were normal. Severe recurrent internal carotid artery stenosis developed in 2 patients at 6 and 9 months, but all 3 completion intraoperative studies at the time of the original operation were normal. Based on these results, wide variability in flowmetry values limits its potential usefulness to detect non-flow-limiting lesions and replace contrast arteriography or duplex ultrasonography as an intraoperative carotid endarterectomy completion study. Duplex ultrasonography was also of limited to no value, whereas contrast arteriography rarely documented a lesion that required repair. [ABSTRACT FROM AUTHOR]

Approximately 10 years ago, the Section of Vascular Surgery at Pennsylvania Hospital reported results of critical pathways that we developed for all major vascular operations, including carotid endarterectomy (CEA). After implementing these pathways, we then developed a specific five-step protocol to further improve results and decrease costs for elective CEA. With the advent of carotid artery balloon angioplasty and stenting (CABAS), CEA has come under increasing attack by endovascular interventionalists. We believe our regimen remains the gold-standard against which CABAS should be compared. Our five-step CEA protocol includes: (1) duplex ultrasonography performed in an accredited vascular laboratory as the sole diagnostic carotid preoperative study, (2) admission the day of surgery, (3) cervical block anesthesia to eliminate intraoperative electroencephalographic monitoring and other costly intraoperative monitoring tests, (4) transfer from the recovery room after a short observation period to the vascular ward, and (5) discharge the first postoperative morning. Since this 5-step protocol was implemented several years ago, we have found it to be safe and cost-effective, and now represents the standard against which CABAS should be compared. [Copyright &y& Elsevier]

Examines the replacement of general anesthesia by cervical block anesthesia for carotid endarterectomy. Intolerance of patient to cervical block anesthesia; Occurrence of neurologic changes when administering cervical block anesthesia; Presence of ipsilateral stroke history in both anesthetic methods.

Infected false aneurysm after carotid endarterectomy is extremely rare, with only 14 cases having been reported in the English-language literature. These can occur even in the absence of prosthetic material. Presentation may be early or delayed, and most patients will develop a tender, pulsatile cervical mass. Surgical therapy can be challenging, with aneurysm excision and autologous interposition grafting the favored approach. The authors report herein a case of postendarterectomy carotid artery infection diagnosed by color-duplex ultrasound, and they review the published experience with this entity. [ABSTRACT FROM AUTHOR]