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Purpose: To study the hemodynamic effects of an arteriovenous fistula (AVF) used as an adjunct to venous reconstructions and to determine the optimal size for such a fistula.Methods: A model of limb circulation with an AVF (in vitro system) was constructed with silicon elastic tubes and 40% glycerin solution as the fluid medium. Pulsatile arterial flow and venous return was maintained with a roller pump and a centrifugal assist device. Flows and pressures were measured for three different fistula diameters (3, 4, and 5 mm). A canine model of venous hypertension with outflow obstruction was constructed in 15 adult mongrel dogs. After 7 to 13 days an externally supported 8-mm expanded polytetrafluoroethylene femorocaval graft was implanted with a distal AVF (3 mm, n = 5; 4 mm, n = 5; 5 mm, n = 5). Arterial and venous flows and venous pressures were measured proximal and distal to the fistula before and after exercise.Results: In the in vitro system, flows through the venous graft increased with increasing fistula size, but venous return decreased progressively, increasing the distal venous pressure. In the canine model, flow in the venous graft increased with each AVF (p < 0.01). Only the 3-mm AVF resulted in decreased distal femoral vein pressure (p < 0.01), orthograde flow, and improved venous return with exercise.Conclusion: AVFs increased flow through the femorocaval grafts, yet they impeded venous return. The ideal AVF-to-graft ratio used in our study was 0.375, because it increased graft flow, permitted forward flow in the femoral vein while reducing pressure, and improved venous return with exercise. (J Vasc Surg 1996;24:793-9.)

Background: Aortic fenestration is rarely required for patients with acute or chronic aortic dissection. To better define its role and the indications for its use and to evaluate its success at relieving organ or limb malperfusion, we reviewed our experience with direct fenestration of the aorta. Methods: A retrospective analysis of all consecutive aortic fenestrations performed between January 1, 1979, and December 31, 1999, was performed. Fourteen patients, 12 men and two women (mean age, 59.6 years; range, 43-81), underwent fenestration of the aorta. All patients were hypertensive and had a history of tobacco use. By Stanford classification, there were three type A and 11 type B patients. In the acute dissection group (n = 7), indications for surgery were malperfusion in six patients (leg ischemia, 4; renal ischemia, 5; bowel ischemia, 3) and intra-abdominal bleeding from rupture in two. In the chronic dissection group (n = 7), indications for surgery were abdominal aortic aneurysm in 4 patients (infrarenal, 3; pararenal, 1), thoracoabdominal aneurysm in 1, hypertension from coarctation of the thoracic aorta in 1, and aortic occlusion with disabling claudication in 1. Results: Emergency aortic fenestration was performed in seven patients (surgically for 6 and percutaneously for 1). Fenestration level was infrarenal in four and pararenal in three. Concomitant abdominal aortic graft replacement was performed in four patients, combined with ascending aortic replacement (n = 1) and bilateral aortorenal bypasses (n = 1). In two patients, acute fenestration was performed for organ malperfusion after prior proximal aortic replacement (ascending aorta, 1; descending thoracic aorta, 1). Seven elective aortic fenestrations were performed for chronic dissection (descending thoracic aorta, 2; paravisceral aorta, 2; infrarenal aorta, 2 and pararenal aorta, 1). Concomitant aortic replacement was performed in six patients (abdominal aorta, 5; thoracoabdominal aorta, 1). Fenestration was successful at restoring flow in all 10 patients with malperfusion. Operative mortality for emergency fenestration was 43% (3/7). The three deaths that occurred were of patients with anuria or bowel ischemia, or both. There were no postoperative deaths for elective fenestration. At a mean follow-up of 5.1 years, there were no recurrences of malperfusion and no false aneurysm formations at the fenestration site. Conclusion: Fenestration of the aorta can effectively relieve organ or limb ischemia. Bowel ischemia and anuria are indicators of dismal prognosis and emergency fenestration in these patients carries a high mortality. Elective fenestration combined with aortic replacement can be performed safely in chronic dissection. Aortic fenestration is indicated for carefully selected patients with malperfusion and offers durable benefits. (J Vasc Surg 2000;32:711-21.)

In recent years, many important discoveries have been made to challenge current policy, guidelines, and practice regarding how best to prevent stroke associated with atherosclerotic stenosis of the origin of the internal carotid artery. The United States Center for Medicare and Medicaid Services (CMS), for instance, is calling for expert advice as to whether its current policies should be modified. Using a thorough review of literature, 41 leading academic stroke-prevention clinicians from the United States and other countries, have united to advise CMS not to extend current reimbursement indications for carotid angioplasty/stenting (CAS) to patients with asymptomatic carotid stenosis or to patients with symptomatic carotid stenosis considered to be at "low or standard risk from carotid endarterectomy (CEA)." It was concluded that such expansion of reimbursement indications would have disastrous health and economic consequences for the United States and any other country that may follow such inappropriate action. This was an international effort because the experts to best advise CMS are relatively few and scattered around the world. In addition, US health policy, practice, and research have tended to have strong influences on other countries.

Spinal cord injury is a rare complication in patients with aortic dissection. The extrinsic arterial supply to the spinal cord, diminishing caudally, often becomes critically dependent on the great radicular artery (GRA) of Adamkiewicz at the thoracolumbar spine. There are no prior reports of spinal injury or ischemia caused by chronic aortic dissection. We report on a 51-year-old patient with chronic type B dissection of the aorta from below the subclavian takeoff through the iliac arteries, presented with multiple episodes of transient (1 to 5 minutes) spinal ischemic attacks, entailing sudden loss of motor and sensory functions in both legs, with collapse of the patient on the ground. GRA imaging acquired with 64-channel computed tomography angiography enabled aortic fenestration from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. We critically appraise the pertinent literature.

Objectives To identify factors affecting long-term outcome after open surgical reconstructions (OSR) and hybrid reconstructions (HR) for chronic venous obstructions. Methods Retrospective review of clinical data of 60 patients with 64 OSR or HR for chronic obstruction of iliofemoral (IF) veins or inferior vena cava (IVC) between January 1985 and September 2009. Primary end points were patency and clinical outcome. Results Sixty patients (26 men, mean age 43 years, range 16-81) underwent 64 procedures. Ninety-four percent had leg swelling, 90% had venous claudication, and 31% had active or healed ulcers (CEAP classes: C3=30, C4=12, C5=8, C6=12). Fifty-two OSRs included 29 femorofemoral (Palma vein: 25, polytetrafluoroethylene [PTFE]: 4), 17 femoroiliac-inferior vena cava (IVC) (vein: 3, PTFE: 14) and six complex bypasses. Twelve patients had HR, which included endophlebectomy, patch angioplasty, and stenting. Early graft occlusion occurred after 17% of OSR and 33% HR. Discharge patency was 96% after OSR, 92% after HR. No mortality or pulmonary embolism occurred. Five-year primary and secondary patency was 42% (95% confidence interval [CI] 29%-55%) and 59% (CI 43%-72%), respectively. For Palma vein grafts it was 70% and 78%, for femoroiliac and ilio-infrahepatic IVC bypasses it was 63% and 86%, and for femoro-infrahepatic IVC bypasses it was 31% and 57%, respectively. Complex OSRs and hybrid procedures had 28% and 30% 2-year secondary patency, respectively. The only factor that significantly affected graft patency in multivariate analysis was May-Thurner syndrome with associated chronic venous thrombosis. For HR, stenting into the common femoral vein patch vs iliac stents only significantly increased patency. At last follow-up, 60% of the patients had no venous claudication and no or minimal swelling. All ulcers with patent grafts healed but 50% of these recurred. Conclusions Both OSR and HR are viable options if endovascular procedures fail or are not feasible. Palma vein bypass and femoroiliac or iliocaval PTFE bypasses have excellent outcomes with good symptomatic relief.

Purpose Ehlers-Danlos syndrome type IV (EDS-IV) results from abnormal procollagen III synthesis and leads to arterial, intestinal, and uterine rupture. The purpose of this study was to review the spectrum, management, and clinical outcome of EDS-IV patients. Methods We retrospectively reviewed the clinical data of 31 patients (15 male and 16 female) with a clinical diagnosis of EDS-IV treated over a 30-year period (1971 to 2001). Biochemical confirmation was obtained in 24 patients, and mutation of the COL3A1 gene was confirmed in 11 patients. The study excluded patients with other connective tissue dysplasias. Results The mean age at the time of diagnosis was 28.5 ± 11 years (range, 10 to 53 years). Twenty-four patients developed 132 vascular complications; of these, 85 were present either before or at the time of the initial evaluation, and 47 complications occurred during a median follow-up of 6.3 years (range, 0.5 to 26 years). Survival free of vascular complications was 90% at age 20 years, 39% at 40 years, and 20% at age 60 years. Fifteen patients underwent 30 operative interventions for vascular complications, including arterial reconstruction (n = 15), simple repair or ligation (n = 4), coil embolization (n = 3), splenectomy (n = 2), and abdominal decompression, nephrectomy, graft thrombectomy, vein stripping and thoracoscopy (n = 1 each). Three hospital deaths occurred from exsanguinating hemorrhage: two after operative interventions and one because of a ruptured splenic artery. Procedure-related morbidity was 46%, including a 37% incidence of postoperative bleeding and a 20% need for re-exploration. The incidence of late graft-related complications was 40% of arterial reconstructions, including 4 anastomotic aneurysms, 1 fatal anastomotic disruption, and 1 graft thrombosis. Patient survival was 68% at age 50 years and 35% at age 80 years. Of the 12 deaths during the study period, 11 were associated with vascular or graft-related complications. Conclusion Operative mortality in patients with vascular complications of EDS-IV was not excessively high, but the incidence of postoperative bleeding complications and late graft-related problems was significant. Despite successful repair of vascular complications, survival was shortened because of secondary vascular or graft-related complications.

ObjectiveTo compare outcomes of mesenteric angioplasty and stenting using iCAST covered stents (CS; Atrium, Hudson, NH) or bare metal stents (BMS) in patients with chronic mesenteric ischemia (CMI).MethodsWe reviewed the clinical data of 225 patients (65 male and 160 female; mean age, 72 ± 12 years) treated for CMI at two academic centers (2000-2010). Outcomes were analyzed in patients who had primary intervention or reintervention using BMS (n = 164 patients/197 vessels) or CS (n = 61 patients/67 vessels). End points were freedom from restenosis, symptom recurrence, reinterventions, and patency rates.ResultsPatients in both groups had similar demographics, cardiovascular risk factors, and extent of disease. In the primary intervention group (mean follow-up, 29 ± 12 months), patients treated by CS had higher freedom from restenosis (92% ± 6% vs 53% ± 4%; P = .003), symptom recurrence (92 ± 4% vs 50 ± 5%; P = .003), reintervention (91% ± 6% vs 56% ± 5%; P = .005), and better primary patency at 3 years (92% ± 6% vs 52% ± 5%; P < .003) than for BMS. In the reintervention group (mean follow-up, 24 ± 9 months), patients treated by CS had higher freedom from restenosis (89% ± 10% vs 49% ± 14%; P < .04), symptom recurrence (100% vs 64%± 9%; P = .001), and reintervention (100% vs 72% ± 9%; P = .03) at 1 year, and a trend toward improved primary patency at 1 year (100% vs 63% ± 9%; P = .054). Secondary patency rates were similar in both groups.ConclusionsIn this nonrandomized study, CS were associated with less restenosis, recurrences, and reinterventions than BMS in patients undergoing primary interventions or reinterventions for CMI.

Median arcuate ligament syndrome (MALS) is a rare disorder resulting from extrinsic compression and narrowing of the celiac artery, and--less often--the superior mesenteric artery, by the relatively low insertion of the ligament and/or prominent fibrous bands or ganglionic periaortic tissue of the celiac nervous plexus. We report on a young woman who after three consecutive attempts of endovascular therapy with balloon angioplasty and stenting for MALS, each followed by gross symptom recurrence and a cumulative weight loss of 10 kg, underwent open surgical division of the ligament and reconstruction of the celiac artery. Despite the initial response of MALS to endovascular therapy, the extrinsic pressure exerted on the celiac artery by the surrounding dense fibrous/ganglionic tissue resulted in slippage of the stents and/or failure of their material. These findings militate against the use of balloon angioplasty and stenting primarily in patients with MALS without prior release of the extrinsic compression on the celiac (and/or superior mesenteric) artery by dividing the surrounding median arcuate ligament and/or ganglionic tissue with open or laparoscopic surgery.

Purpose: Experiments were designed to determine effects of dietary supplementation with L -arginine on structure and function of flow-restricted vein grafts. Methods: Saphenous veins were placed as bilateral interposition grafts in femoral arteries of two groups of adult male mongrel dogs; one group was maintained on a normal diet (control), the other group supplemented with L -arginine (200 mg/kg per day) beginning 1 week before surgery. In each dog, flow was reduced by 50% in one graft by placing an adjustable clamp on the artery distal to the distal anastomosis. Plasma amino acids and oxidized products of nitric oxide (NO x ) were measured before and after L -arginine feeding. At postoperative week 4, grafts were removed and prepared for organ chamber studies to determine functions of the endothelium or smooth muscle and for histology. Results: Plasma L -arginine increased within 3 hours after feeding and increased from 141 ± 8 nmol/mL to 169 ± 11 nmol/mL (n = 6) after 5 weeks of supplementation. Plasma ornithine and citrulline paralleled arginine, whereas circulating NO x was unchanged. Maximal contractions to 60 mmol/L KCl were reduced in grafts from L -arginine–fed dogs. Endothelium-dependent relaxations to the calcium ionophore A23187 and relaxations of the smooth muscle NO were reduced in grafts from L -arginine–fed dogs. Neointimal hyperplasia was increased in grafts with reduced flow and not affected by arginine feeding. Conclusions: Dietary supplementation with L -arginine did not increase plasma NO in dogs with peripheral vein grafts or increase endothelium-dependent relaxations in control or flow-restricted grafts. Therefore, dietary supplementation with L -arginine may not improve long-term functions of flow-restricted peripheral bypass grafts. (J Vasc Surg 2001;33:829-39.)

A 70-year-old man had an unusual type of supravesical small bowel hernia associated with herniation of the bladder through a traumatic diastasis of the pubic symphysis. The diastasis was closed with prosthetic mesh through a preperitoneal approach. In patients in whom a scrotal hernia develops after a previous pelvic fracture, especially those with evidence of a pubic diastasis, an unusual type of hernia should be suspected. A preperitoneal surgical approach best reveals the anatomy and allows appropriate repair. The best procedure for prevention of such hernias is primary reduction of any substantial pubic diastasis, but operative intervention is not indicated in all patients.

Because of the increasing need for a reliable prosthetic microvascular graft, we investigated the patency of expanded PTFE with and without platelet inhibitor medication as an arterial prosthesis (1 by 10 mm) placed in the aorta of the rat using standard microsurgical technique. In 10 animals without platelet-inhibitor medication, one graft (10 percent) was patent at 30 days. When the platelet inhibitor ibuprofen was given for the initial 15 days to 10 animals, all 10 grafts (100 percent) remained patent at 30 days without further use of the drug. There was a significant difference between the patency achieved with the drug and that obtained without it (p less than 0.0001). The results of this experimental study demonstrate that expanded PTFE can successfully be used as a microvascular graft in the rat with excellent patency (100 percent at 30 days) when combined with ibuprofen therapy.

To evaluate results of medical and surgical treatment of axillary-subclavian venous occlusion, the clinical courses of 95 patients were reviewed. Twenty-three patients had acute axillary-subclavian venous thrombosis, and 72 patients had chronic occlusion. Thirty-four patients with thoracic outlet syndrome and axillary-subclavian occlusion represented 3.5% of the 969 patients treated for thoracic outlet syndrome during the same period. Nonlethal pulmonary embolization from the axillary-subclavian vein occurred in four patients. Sixty percent of patients were asymptomatic or had mild symptoms during strenuous exercise at last follow-up (mean, 5.4 years). Forty-eight of these 56 patients had received anticoagulation during the acute phase of the disease. Twenty-seven percent of patients had symptoms with moderate exercise and 12.6% had symptoms at rest. Thirteen patients had operations, with improvement demonstrable in 10 patients. All five patients who underwent first rib resection for intermittent venous occlusion or for thoracic outlet syndrome after thrombosis occurred on the contralateral side did well. Axillary-subclavian venous occlusion is a nonlethal disease but late sequelae occur in one third of patients. Early anticoagulation appears to be beneficial and, in some patients with concominant thoracic outlet syndrome, first rib resection also appears to be helpful. Further data are needed to evaluate results of fibrinolytic treatment, thrombectomy, and venous reconstruction. (J VASC SURG 1986;4:333-7.)

Seventeen patients (15 men and two women) underwent operation for concomitant abdominal aortic aneurysm (AAA) and colorectal carcinoma (Ca) during a recent 12-year period. Ages ranged from 59 to 89 years (median 75.2 years). Diameter of the AAA ranged from 3.5 to 9.5 cm (median 5.5 cm). The Ca was staged by the Astler-Coller modification of Dukes' classification as B1 in three patients, B2 in eight, C2 in three, D in two, and unclassified in one. Personal preference, presence of symptoms, and extent of malignant involvement determined preference of resection. The Ca was eventually resected in 16 patients and the AAA in nine. Thirteen patients underwent resection of the Ca first, two the AAA first, and two concomitantly. Eight patients (47%) underwent resection of both the AAA and Ca, eight underwent resection of the Ca only, and one underwent resection of the AAA only. There were three deaths in 24 operations. Follow-up ranged from 5 weeks to 8 years (median 1 ½ years). Only five patients (29.4%) were long-term survivors without evidence of recurrent Ca and all occurred in the eight patients (62.5%) who had undergone resection of both the Ca and AAA. Three late deaths occurred as a result of complications from the unresected AAA in the eight patients who had undergone resection of the Ca only (37.5%). We conclude that if the Ca is not symptomatic and localized the AAA should be resected first. However, both lesions need to be resected eventually for long-term survival. (J Vasc Surg 1989;9:630–6.)

Animal studies have been conducted to determine the effectiveness of ibuprofen in reducing early platelet deposition on small diameter (4 mm) Gore-Tex (polytetrafluoroethylene) arterial grafts and larger (10 mm) Gore-Tex grafts placed in the inferior vena cava. These studies demonstrated a significant reduction ln platelet deposition at one and three hours. Additional studies of animals undergoing treatment with ibuprofen and subjected to arterial replacement with 1 or 4 mm Gore-Tex grafts demonstrated enhanced patency at 30 days. Cautious evaluation of Ibuprofen as an adjunct in vascular surgery appears warranted.

To evaluate the effect of ibuprofen on early thrombus formation following inferior vena cava (IVC) replacement, a 4-cm segment of IVC was replaced with a 5-cm (10-mm-i.d.) segment of reinforced polytetrafluoroethylene (PTFE) graft in 12 dogs. Autologous platelets and canine fibrinogen were labeled with 111In and 125I, respectively, and injected into each animal 24 hr prior to vena cava replacement. Six dogs served as controls and six were treated with 12.5 mg/kg ibuprofen intravenously 1 hr preoperatively. All dogs were heparinized with 100 U/kg intravenous heparin prior to crossclamping the IVC: heparin was not reversed at the end of the procedure. Three hours after normal circulation was restored, the grafts were removed and counts of radioactivity made. All grafts were patent. The mean platelet count for the control group was 12.8 X 10(6)/mm2, while in the grafts from the treated group it was 0.960 X 10(6)/mm2. The decreased platelet deposition was significant in all graft segments (P less than 0.01). Fibrin deposition was reduced from 3.38 micrograms/mm2 to 0.25 micrograms/mm2 (P less than 0.01) by ibuprofen. Although fibrin and red blood cells are the major constituents of venous thrombi, platelet aggregation appears to play an important role if prosthetic material is implanted into the venous system. Ibuprofen not only reduced platelet deposition by 13.5-fold, but also reduced fibrin deposition by 13.5-fold. The ratio of platelets to fibrin in control and treated animals was similar (3.84 and 3.79, respectively). These data suggest that antiplatelet medication combined with heparin therapy might decrease early thrombus formation in venous prostheses.

The Klippel-Trenaunay syndrome is a congenital vascular anomaly consisting of the triad of soft-tissue and bony hypertrophy of the extremities, hemangiomas and/or lymphangiomas, and varicosities. From 1956 to 1983, 42 patients with the Klippel-Trenaunay syndrome were seen at the Mayo Clinic. Of the 42 patients, 16 had involvement of the trunk (thorax, abdomen and/or pelvis). Twelve of the 16 had evidence of the malformation at birth and 4 had evidence shortly thereafter. Lesions involving the trunk included hemangiomas (75%) and lymphangiomas (50%). Complications included rectal bleeding, hematuria, colonic obstruction, hemothorax, paraparesis secondary to clotting disorder, and compression of the external urethral meatus. One child died of enlargement of diffuse lymphangiomas and hemangiomas of the abdomen and chest. Eight of the 16 patients underwent 13 operative procedures. These included excision of the superficial lymphangiomas, resection of the rectosigmoid colon, and resection of an extremely large retroperitoneal mass of hemangiomatous-lymphangiomatous tissue. While progression requiring major surgery was seen in several patients, most patients had supportive therapy, with minimal surgery being necessary.

The natural process of endothelialization, pseudointimal formation, and connective tissue incorporation of the expanded PTFE grafts in the goat was documented through histologic examination of specimens harvested at 2, 4, 6, and 8 weeks. The goats demonstrated a progressive increase in pseudointimal pannus ingrowth from the anastomoses at a rate of 11.3 mm over a 12 week period. Histologic changes according to time of vascular graft incorporation in the goat model were found to be comparable to those of the dog, pig, and calf models reported in the literature. Platelet-inhibiting drugs, aspirin, dipyridamole, nifedipine, and ibuprofen were administered to goats after replacement of their infrarenal aorta with 5 cm of 8 mm diameter expanded PTFE grafts. The effects of the drugs on graft endothelialization and anastomotic pseudointimal formation was compared with those in the untreated control group after 12 weeks. Aspirin and dipyridamole had no detrimental effect on the healing process compared with the untreated control group. Studies with nifedipine and ibuprofen did not demonstrate a decrease in pseudointimal hyperplasia. Antiplatelet treatment resulted in no significant change in the rate of endothelialization of expanded PTFE grafts.

Between January 1956 and July 1981, 40 patients with Klippel-Trenaunay syndrome were seen at the Mayo Clinic. Twenty male and 20 female patients presented with the classic triad of soft tissue and bony hypertrophy of the extremity, hemangioma, and varicosity without evidence of functional arteriovenous fistulae. The lower extremity was involved in 38 patients (95%), the upper extremity in six patients (15%). In four of these cases (10%), both the upper and lower extremities were affected. The disease was unilateral in 34 patients (85%), bilateral in five cases (12.5%), and crossed-bilateral in one case (2.5%). Surgery was done in 13 patients (32.5%), nine of whom were operated on at the Mayo Clinic and four of whom had had previous surgery elsewhere. Excision and stripping of varices were performed in three patients; of these three, a deterioration of symptoms was observed in one, but the procedure was beneficial in the other two. Partial varicectomy was performed in four cases, while resection of the angioma was attempted in eight cases, with good results in three cases of small angiomas. Femoral and tibial epiphysiodesis stopped the overgrowth and produced an excellent result in one case. In four cases of epiphysiodesis at the foot level and two cases of derotational tibial osteotomy, moderate improvement was achieved. The indication for vascular or orthopedic surgery should be carefully considered in each patient who has this syndrome. One patient (2.5%) died of a severe form of the disease, but the relatively benign course is documented by the 21 patients (52.5%) who are free of complaints without any treatment or with elastic support only.

This study was designed to quantitatively evaluate the effects of an antiplatelet agent, ibuprofen, on mural thrombus formation and pseudointimal development in the endarterectomized canine aorta. A 3 cm segment of abdominal aorta was endarterectomized in 18 dogs. Nine dogs served as controls and nine dogs were treated with ibuprofen (12.5 mg/kg) given intravenously 1 hour preoperatively and orally (7.5 mg/kg) three times a day in the postoperative period. Three dogs were killed from each group at 7, 14, and 21 days. Healing of the endarterectomized aortic segment was assessed by means of computer-assisted surface morphometry, light microscopy, and both scanning and transmission electron microscopy. One week postoperatively, the thrombus-free surface in the treated dogs was 75 percent, compared with 20 percent in control animals; at 2 weeks 97 percent, compared with 38 percent and at 3 weeks 98 percent, compared with 38 percent (p less than 0.01 for each group). The thickness of the pseudointima was 9 percent of the aortic wall thickness in treated dogs compared with 60 percent in control animals 1 week postoperatively (p less than 0.001); at 2 weeks 24 percent in treated animals and 64 percent in control animals (p less than 0.001); and at 3 weeks 31 percent in treated animals and 55 percent in control animals (p less than 0.05). Partial reendothelialization was observed 1 week postoperatively and complete reendothelialization at 3 weeks in both the control and treated animals. These data suggest that administration of preoperative and maintenance therapy with ibuprofen significantly reduces mural thrombus formation and pseudointimal thickness in the endarterectomized canine aorta.

In open surgical reconstruction for chronic iliofemoral and iliocaval vein obstruction, addition of an arteriovenous fistula (AVF) can improve patency. The AVF is usually taken down in a second surgical procedure several months after the initial reconstruction. With the advancement of endovascular techniques, percutaneous closure of the fistula has become an option. We have completed percutaneous endovascular takedown of AVFs after surgical reconstruction of iliofemoral veins in three patients using an occlusion device. Complete occlusion was achieved in all cases, and no short-term complications were noted. Endovascular occlusion seems particularly appealing as further surgery in a groin usually scarred by previous open procedures can be avoided.

• A 73-year-old woman with a two-year history of recurrent episodes of respiratory distress is described. The finding of an elevated triglyceride value of 23.4 mmol/L (2072 mg/dL) and a normal cholesterol value in her sputum led to the correct diagnosis of chyloptysis after lymphangiography was performed. It is thought that congenital incompetence of the lymphatic valves was the cause of chyloptysis. (Arch Intern Med1988;148:1465-1466)

• Between 1980 and 1986, 101 nondissecting thoracoabdominal aortic aneurysms (TAAAs) were repaired at the Mayo Clinic, Rochester, Minn. Overall mortality was 15% with a 9.6% mortality for elective repair. Nonfatal complications occurred in 44% of patients and included myocardial infarction in 9%, paraplegia in 5%, and renal failure in 4%. In an attempt to reduce morbidity and mortality associated with TAAA repair, one of our vascular surgical services set up a routine protocol of preoperative evaluation, standardized operative technique, and specific guidelines for perioperative management. Fifty-five of the 101 patients underwent elective repair on this service without the use of shunts or bypass. Mortality was reduced to 1.8% and the rate of myocardial infarction was reduced to 1.8%; none of these patients developed renal failure. However, paraplegia/paraparesis still occurred in 5.4% and pulmonary insufficiency occurred in 29%. Preoperative cardiac evaluation and intraoperative reduction of cardiac afterload are important factors in reducing myocardial infarction and death associated with TAAA repair and should be integrated into the management of these patients. However, preexisting pulmonary and renal disease in some patients may limit the surgeon's ability to reduce rates of some complications. ( Arch Surg 1988;123:871-875)

ObjectiveTo compare the clinical characteristics, anatomy, and outcomes of patients treated with open mesenteric revascularization (OR) for chronic mesenteric ischemia (CMI) before and after the preferential use of endovascular revascularization (ER).MethodsWe reviewed a prospective database of 257 patients treated for CMI with OR or ER from 1998 to 2009. Treatment trends were analyzed to identify changes in practice paradigm. Prior to 2002, OR was used in 58 of 81 patients (72%). Since 2002, ER surpassed OR as the most common treatment option; OR was indicated in 58 of 176 patients (33%) who either failed ER or had unfavorable lesions for stent placement. We analyzed differences in clinical data, anatomical characteristics, and outcomes in 116 patients treated with OR before (Pre-Endo, n = 58) and after 2002 (Post-Endo, n = 58). Anatomical characteristics were determined by a blinded investigator using conventional angiography, magnetic resonance angiography, and computed tomography angiography with centerline of flow measurements.ResultsBoth groups had similar demographics, risk factors, and clinical presentation, with the exception of higher (P < .05) rates of hypertension, hyperlipidemia, cardiac interventions, dysrhythmias, and higher comorbidity scores in the Post-Endo group. This group also had more extensive mesenteric artery disease, including higher incidence of three-vessel involvement (76% vs 57%; P = .048) and superior mesenteric artery (SMA) occlusion (67% vs 41%;P = .005). There were no differences (P > .05) in the number of vessels revascularized (1.8 ± 0.4 vs 1.7 ± 0.5) and in graft configuration (antegrade, 91% vs 78%; retrograde, 9% vs 22%; two-vessel, 69% vs 81%) in the Pre- and Post-Endo groups, respectively. There were no differences in operative mortality (1.7% vs 3.4%), morbidity (43% vs 53%), length of stay (12 ± 1 vs 12 ± 1 days), and immediate symptom improvement (88% vs 86%) in the Pre- and Post-Endo groups, respectively. Mean follow-up was 57 ± 6 months for patients treated before 2002 and 29 ± 6 months for those treated after 2002 (P = .0001). At 5 years, primary and secondary patency rates and recurrence-free survival were 82%, 86%, and 84% in the Pre-Endo and 81%, 82%, and 76% in the Post-Endo groups (P > .05).ConclusionOR has been used in approximately one-third of patients treated for CMI since 2002. Despite more comorbidities and more extensive mesenteric artery disease in patients now treated with OR, outcomes have not changed compared with those operated prior to the preferential use of mesenteric stents before 2002.

ObjectiveThe purpose of this study was to compare outcomes after endovascular repair (ER) and contemporary open repair (OR) of popliteal artery aneurysms (PAAs).MethodsClinical data of PAA patients treated between 2005 and 2012 were reviewed. Primary end points were major adverse events (MAEs) including mortality, major amputation, patency, complications, and reinterventions.ResultsA total of 149 PAAs were treated in 120 patients (mean age, 74 ± 10 years). ER was performed in 42 limbs of 35 men (mean age, 81 ± 6.5 years), in 32 electively and in 10 emergently. Technical success was 98%. The 30-day MAEs were more frequent after emergent repair (50% vs 9%; odds ratio [OR], 9.67; 95% confidence interval [CI], 1.74-54; P = .01); mortality and amputation rate was 0% after elective repair, 20% after emergent repair. Mean follow-up was 2.6 years (1 month-6.5 years); 3-year freedom from MAEs was lower after emergent repair than after elective repair (40% vs 66%; hazard ratio [HR], 3.13; 95% CI, 1.10-8.85; P = .03). OR was performed in 107 limbs of 91 patients (90 men; mean age, 71 ± 9.6 years), in 93 electively and in 14 emergently. The 30-day MAEs were more frequent after emergent repair (43% vs 5%; OR, 13; 95% CI, 3.29-53; P < .001); mortality was 1% after elective repair, 0% after emergent cases. Amputation rate was 0% for both elective and emergent repairs. Mean follow-up was 3.8 years (1 month-8.4 years); 3-year freedom from MAEs was lower after emergent repair (50% vs 80%; HR, 3.78; 95% CI, 1.55-9.20; P = .003). The 30-day MAE rates were equivalent between ER and OR independent of urgency of repair (elective: OR, 1.82; 95% CI, 0.41-8.09; P = .43; emergent: OR, 1.33; 95% CI, 0.26-6.81; P = .73). In elective interventions, ER had a trend to decreased freedom from MAEs (66% vs 80% at 3 years; HR, 1.93; 95% CI, 0.92-4.07; P = .08); freedom from reintervention was lower after ER (72% vs 88%; HR, 2.41; 95% CI, 1.02-5.70; P = .046). In emergent interventions, 1-year freedom from MAEs was similar (40% vs 50%; HR, 1.36; 95% CI, 0.49-3.74; P = .55). Emergent ER and poor runoff predicted MAEs.ConclusionsOur study failed to prove the superiority of ER over OR. If anatomy is suitable, ER of PAA in the elderly and high-risk patients is justified. For emergent PAA repairs, MAEs are frequent after both ER and OR; ER has not changed the severe prognosis of acute limb ischemia from PAA. A multicenter randomized controlled trial of PAA patients with acute presentation is warranted.

S OF THE 2013 VASCULAR ANNUAL MEETING V1: Peripheral Vascular Surgery Society Paper Session I

ObjectiveOutcomes of open (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed with respect to clinical risk stratification.MethodsThe data of 229 consecutive patients treated for CMI with OR (146 patients/265 vessels) or ER (83 patients/105 vessels) between 1991 and 2005 were reviewed. Patients were classified as low-risk or high-risk using standard scoring systems. End points were mortality and morbidity, recurrence-free survival, and patency rates. A subset analysis compared 111 patients (208 vessels) who had OR with 58 patients (76 vessels) who had stenting.ResultsThe ER patients were significantly older (71 ± 15 vs 65 ± 11 years; P < .05), had higher risk (58% vs 31%), and fewer vessels revascularized (1.3 ± 0.5 vs 1.8 ± 0.4). Four (2.7%) procedurally related deaths occurred in the OR and two (2.4%) in the ER group (P = NS). Mortality was higher for high-risk patients (OR, 6.7% vs 0.9%; ER, 4.8% vs 0%; P < .05), but differences were not significant among low-risk or high-risk OR vs ER patients. OR patients had more complications (36% vs 18%; P < .001) and longer hospitalization (12 ± 8 vs 3 ± 5 days; P < .001). At 5 years, OR had improved (P < .05) recurrence-free survival (89% ± 4% vs 51% ± 9%), and primary (88% ± 3% vs 41% ± 9%) and secondary patency rates (97% ± 2% vs 88% ± 4%). More restenoses (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.4-10.2), recurrences (HR, 6.7; 95% CI, 3.3-13.8), and reinterventions occurred in the ER group (HR, 4.3; 95% CI, 1.9-9.7). At last follow-up, significant symptom improvement was noted in 137 OR (96%) and 72 ER patients (92%, P = NS). In the subset analysis of patients having first-time operations vs stenting, OR resulted in improved (P < .05) recurrence-free survival (91% ± 3% vs 56% ± 8% at 5 years) and better primary and secondary patency rates (93% ± 2% and 98% ± 1% vs 52% ± 8% and 93% ± 4% at 3 years).ConclusionOR has similar mortality but higher morbidity and longer hospitalization than ER in low-risk or high-risk patients with CMI. Both treatments effectively improved symptoms, but restenosis, recurrent symptoms, and reinterventions were more likely in ER patients. These findings may guide treatment selection and counseling of low-risk and high-risk CMI patients undergoing OR or ER procedures.

Objective This study reviewed the outcomes of open and endovascular revascularization for mesenteric vasculitis (MV). Methods We reviewed the clinical data of all patients who underwent revascularization for occlusive MV from 1984 to 2008. Patients treated for aneurysms or mucosal bleeding without ischemic symptoms were excluded. End points were early mortality and morbidity, survival, freedom from mesenteric symptoms, and patency. Outcomes of open reconstructions were compared with the results of 163 patients who underwent open operations for atherosclerotic disease. Results There were 15 patients (13 females, 2 males) with a mean age of 38 years (range, 15-66 years). Etiologies were Takayasu's arteritis in 7, polyarteritis nodosa in 4, indeterminate in 3, and giant cell arteritis in 1. The celiac axis was affected in 13, superior mesenteric artery (SMA) in 13, renal arteries in 8, and the aorta in 4. Seven patients had active disease, and eight were in remission. Nine (60%) presented with symptomatic chronic (n = 8) and acute (n = 1) mesenteric ischemia. Six patients with asymptomatic disease underwent mesenteric revascularization during other aortic-based operations. Fourteen patients (93%) had 10 mesenteric bypasses (8 aortic based; 2 iliac), three had aortoplasties, of which two had mesenteric patch angioplasties, and one underwent arcuate ligament release with patch angioplasty. One patient (7%) underwent percutaneous transluminal angioplasty of SMA stenosis. There were no early deaths. Early complications occurred in three patients (20%) after open reconstruction, including gastrointestinal hemorrhage, ileus with re-exploration, and superior mesenteric vein thrombosis. Median follow-up was 22 months. One graft thrombosis in a patient with active disease was treated with redo bypass 74 months after aorta-celiac-SMA bypass. All patients were alive at 10 years, with similar expected survival compared with the general population (P = .69). Compared with patients with atherosclerotic disease, open reconstructions for MV had similar freedom from mesenteric symptoms (83% vs 75%, P = .80) and similar primary graft patency (83% vs 84%, P = .9). Conclusion Mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, indeterminate, or giant cell arteritis. Open revascularization is durable and effective when needed.

PurposeFew large series document surgical outcomes for patients with pararenal abdominal aortic aneurysms (PAAAs), defined as aneurysms including the juxtarenal aorta or renal artery origins that require suprarenal aortic clamping. No standard endovascular alternatives presently exist; however, future endovascular branch graft repairs ultimately must be compared with the gold standard of open repair. To this end, we present a 10-year experience.MethodsBetween 1993 and 2003, 3058 AAAs were repaired. Perioperative variables, morbidity, and mortality were retrospectively assessed. Renal insufficiency was defined as a rise in the concentration of serum creatinine by ≥0.5 mg/dL. Factors predicting complications were identified by multivariate analyses. Morbidity and 30-day mortality were evaluated with multiple logistic regression analysis.ResultsOf a total of 3058 AAA repairs performed, 247 were PAAAs (8%). Mean renal ischemia time was 23 minutes (range, 5 to 60 minutes). Cardiac complications occurred in 32 patients (13%), pulmonary complications in 38 (16%), and renal insufficiency in 54 (22%). Multivariate analysis associated myocardial infarction with advanced age (P = .01) and abnormal preoperative serum creatinine (>1.5 mg/dL) (P = .08). Pulmonary complications were associated with advanced age (P = .03), renal artery bypass (P = .02), increased mesenteric ischemic time (P = .01), suprarenal aneurysm repair (P < .0008), and left renal vein division (P = .01). Renal insufficiency was associated with increased mesenteric ischemic time (P = .001), supravisceral clamping (P = .04), left renal vein division (P = .04), and renal artery bypass (P = .0002), but not renal artery reimplantation or endarterectomy. New dialysis was required in 3.7% (9/242). Abnormal preoperative serum creatinine (>1.5 mg/dL) was predictive of the need for postoperative dialysis (10% vs 2%; P = .04). Patients with normal preoperative renal function had improved recovery (93% vs 36%; P = .0002). The 30-day surgical mortality was 2.5% (6/247) but was not predicted by any factors, and in-hospital mortality was 2.8% (7/247). Median intensive care and hospital stays were 3 and 9 days, respectively, and longer stays were associated with age at surgery (P = .007 and P = .0002, respectively) and any postoperative complication.ConclusionsPAAA repair can be performed with low mortality. Renal insufficiency is the most frequent complication, but avoiding renal artery bypass, prolonged mesenteric ischemia time, or left renal vein transection may improve results.

Objectives: To compare long-term outcomes after OR vs EVAR of AAAs at a tertiary center. Methods: Clinical data of consecutive AAA patients treated electively between 2000 and 2011 were retrospectively reviewed. Primary endpoint was all-cause mortality, secondary endpoints were complications, reinterventions and ruptures. Propensity score-based matching included age, gender, year of intervention and comorbidities was performed to compare outcomes. Results: There were 1350 matched cohorts (mean age 74 6 7 years). Thirty-day mortality was 1.3% after OR, 1.0% after EVAR (P 1⁄4 .40). Early complications were lower after EVAR (13% vs 25%; P < .0001). Mean follow-up was 4.2 years (30 days-12.7 years). At 5 years, all-cause mortality was lower, freedom from reintervention higher after OR (23% vs 32%, 87% vs 74%); freedom from complications the same (66%). In multi-variable analysis, SVS-comorbidity score and age were associated with allcause mortality. Results were similar in 1791 unmatched cohorts. There were 2 ruptures after OR, 8 after EVAR (P 1⁄4 .02). Conclusions: Both elective OR and EVAR have low early mortality, EVAR has fewer early complications. Advanced age and comorbidities predict high late mortality. This study failed to support long-term benefits of EVAR, since the procedure was associated with increased rates of late all-cause mortality, reinterventions and small but definite risk of late rupture.

Purpose Neurofibromatosis type I (NF-I) is an autosomal dominant disorder affecting one in 3000 individuals. Vascular abnormalities are a well-recognized manifestation of NF-I. The purpose of this study is to review the spectrum, management, and clinical outcome of patients with vascular abnormalities and NF-I. Methods We retrospectively reviewed 31 patients (15 males, 16 females) with clinical NF-I and vascular abnormalities identified from imaging or operative findings between 1976 and 2005. Results The diagnosis of NF-I was made at a mean age of 11 ± 10 years with vascular lesions identified at a mean age of 38 ± 16 years. There were 76 vascular abnormalities, including 38 aneurysms, 20 arterial stenoses, 5 arteriovenous malformations (AVM), 5 arteries compressed or invaded by neural tumors, and 6 abnormalities of the heart valves. Arterial lesions were located in the aorta (n = 17) and in the renal (n = 12), mesenteric (n = 12), carotid-vertebral (n = 10), intracerebral (n = 4), and subclavian-axillary and iliofemoral arteries (3 each). Interventions were required in 23 patients (74%); 15 underwent 24 arterial reconstructions, including 9 renal, 8 aortic, 4 mesenteric, 2 carotid, and 1 femoral. The other eight patients had excision of AVM in three, vessel ligation in two, and clipping of cerebral aneurysms, coil embolization of hepatic aneurysms, and left thoracotomy in one patient each. One patient died of ruptured abdominal aortic aneurysm. Six patients (26%) had postoperative complications, including pneumonia in two, and stroke, acalculous cholecystitis, brachial plexopathy and chylothorax in one patient each. The median follow up was 4.1 years (range, 6 months to 20 years). Late vascular problems developed in three patients, including graft stenoses in two and rupture of another aortic aneurysm in one. Freedom from graft-related complications was 83% at 10 years. Patient survival at 10 years was 77%, less than the 86% expected survival for the general population ( P Conclusion Patients with NF-I have a wide spectrum of vascular abnormalities, most notably aneurysms or stenoses of the aortic, renal, and mesenteric circulation. Operative treatment of symptomatic patients with vascular lesions or large aneurysms is safe, effective, and durable.

Objectives: To determine the utility of routine postoperative troponin (PO Tn) measurements in patients undergoing major vascular surgical reconstructions (VSRs). Methods: Data from consecutive patients undergoing VSRs and routine PO Tn measurement over one year, January 1 to December 31, 2010, were retrospectively analyzed. A positive troponin (Tn) panel included a baseline level immediately after the procedure of $ .20 ng/mL, or a delta at 3 and/or 6 hours of $ .30 ng/mL/$ 20%. Patients without complete Tn panels and research authorization were excluded. Cox Proportional hazards model was used to evaluate the effect of preoperative risk factors and postoperative Tn levels on early and mid-term mortality. Results: Of 725 patients undergoing VSRs 678 (462 males, 216 females; mean age 69 years) satisfied criteria for inclusion. Procedures included 408 open, 196 endovascular and 73 hybrid (306 abdominal, 197 infrainguinal, 40 thoracoabdominal, 117 cerebrovascular and 18 upper extremity). Tn levels were elevated in 67 patients (10%; M: 42, F: 25) and after consultation with a cardiologist were ascribed to non-ST elevation myocardial infarction (NSTEMI) in 26, STEMI in six, demand ischemia in 29 and renal insufficiency in six. Sixty-one patients were managed medically; six underwent cardiac catheterization and intervention. Thirty-day mortality was significantly higher in Tn+ compared to Tnpatients (7.6% vs 1.7%; P 1⁄4 .08). On multivariate analysis abnormal delta Tn (P 1⁄4 .008; HR, 2.0; 95% CI, 1.2-3.4) and SVS/AAVS comorbidity score >9 were associated with mortality. The cumulative probability of death in Tn+ patients remained significantly higher at 1 (27.6% vs 10.6%; P 1⁄4 .004) and 2 years (40.8% vs 18.5%; P 1⁄4 .002). Conclusions: Elevated delta troponin levels following major vascular surgical procedures are independently associated with higher 30 day and mid-term mortality, and this marker should be considered an important prognostic indicator. Author Disclosures: T. C. Bower: Nothing to disclose; R. David: Nothing to disclose; A. A. Duncan: Nothing to disclose; M. D. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; W. Harmsen: Nothing to disclose; M. Kalra: Nothing to disclose; J. Manunga: Nothing to disclose; G. S. Oderich: Nothing to disclose. PS62.

A 9-year-old boy was referred to our institution for management of severe renovascular hypertension (controlled with 6 antihypertensive medications), postprandial abdominal pain, and bilateral lower-limb claudication. He was diagnosed with neurofibromatosis at age 6, manifested by multiple cafe-au-lait macules ( 5cm), axillary and inguinal freckling, and brain lesions on magnetic resonance imaging consistent with neurofibromas. Physical findings included a midepigastric bruit and attenuated lower limb arterial pulses (ankle-brachial index (ABI), 0.67[Rt]/0.7[Lt]). Digital subtraction angiography revealed segmental narrowing of the abdominal aorta frombelowtheceliac to the inferiormesenteric artery (meanpressuregradient 30mmHg)andorificial stenoses ( 75%)of the right renal (A)andsuperiormesenteric arteries (A, insert). Investigation excluded a pheochromocytoma. Surgery, through a midline incision, entailed an aortoaortic bypass (14-mm gelatin-coated polyester) from the supraceliac to distal infrarenal aorta, tunneled posterior to the left kidney, and a retrograde bypass to the superior mesenteric (end-to-side) and right renal (end-to-end) arteries, using 6-mm collagen-coated polyester grafts from the infrarenal aorta (B [Cover]). The patient was discharged on the fifth post-operative day on a single antihypertensive medication, with normal pulses and pressure indexes (ABI, 1.07[Rt]/1.09[Lt]), and a serum creatinine of 0.86. Four months postoperatively the child was normotensive on no drug treatment, free of abdominal pain and claudication, with all of his grafts patent and stenosis-free, as depicted in 3-dimensional contrast computed tomography imaging of the reconstructed aortovisceral circulation (C). Segmental narrowing of the abdominal aorta, designated middle aortic syndrome (MAS), represents an uncommon variety (0.5%-2%) of aortic coarctations attributable to acquired or congenital etiologies. Acquired etiologies include non-specific (Takayasu’s) and giant cell arteritis and neurofibromatosis, whereas congenital aortic hypoplasia is ascribed to a developmental anomaly in the fusion and maturation of the paired embryonic dorsal aortas. 1-4