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When polytetrafluoroethylene (PTFE) must be used for below-knee bypass to achieve limb salvage, effective anticoagulation with warfarin may improve graft survival. We analyzed our practice of routinely using oral anticoagulation to improve graft patency rates for PTFE grafts to below-knee popliteal and crural vessels in limb salvage procedures. We reviewed our established vascular database from February 1999 through April 2003 to identify those patients who required below-knee and tibial artery bypass with PTFE for critical limb ischemia. All patients were initiated on warfarin anticoagulation postoperatively, with an international normalized ratio (INR) of 2.0-3.0 considered therapeutic. All patients were discharged in the therapeutic range. Life-table analysis and Kaplan-Meier estimates were used to compare primary patency rates with regard to INR and position of distal anastomosis. Cox proportional hazards analysis was performed to compare the patency rates for grafts with therapeutic versus subtherapeutic anticoagulation while correcting for variability in distal runoff. Between February 1999 and April 2003, 74 patients (mean age, 69.2 years; 58% men) had 77 below-knee PTFE bypasses. Indications for operation included rest pain (43), ischemic ulcer (27), and gangrene (7). Patients presenting with occluded grafts more often had a subtherapeutic INR. Patients with a subtherapeutic INR (< or = 1.9) had a median primary graft patency of 6.8 months and those with a therapeutic INR (> or = 2.0) had a median primary graft patency of 29.9 months (p = 0.0007). Analysis by Cox proportional hazards model demonstrated a significantly better graft patency rate in patients with a therapeutic INR regardless of outflow vessel. The patency rates of PTFE grafts to infrageniculate vessels may be improved by effective anticoagulation with warfarin. This improved patency rate may also result in improved limb salvage and further support the use of PTFE grafts for critical limb ischemia when autogenous vein is not available. Predictably, the best results are seen with an INR therapeutic range of 2.0 to 3.0.

Stent placement in a tibial artery for suboptimal angioplasty results has had a high rate of restenosis and occlusion due to neointimal hyperplasia. Drug-eluting stents may provide a new therapeutic option in this situation. We describe the use of a Cypher drug-eluting stent after suboptimal angioplasty result in a claudicant with a severe tibioperoneal trunk lesion and single-vessel runoff to the foot with 6-month follow-up., (2005 Wiley-Liss, Inc.)

When an autologous vein is not available for lower extremity revascularization, prosthetic grafts are often required. However, prosthetic bypass grafts have limited patency for infrageniculate reconstruction. To potentially improve patency, a new geometric modification of the polytetrafluoroethylene (PTFE) graft, Distaflo (Impra, Tempe, AZ), has been developed for lower extremity bypass. We reviewed our early experience with the Distaflo graft in patients who required infrageniculate bypass for lower extremity ischemia when no suitable autologous saphenous vein was available. All patients were maintained on warfarin anticoagulation postoperatively. All grafts were followed at 6- to 12-week intervals with duplex ultrasound evaluation. Patient characteristics, operative procedures, and graft surveillance information were maintained on a computerized registry. Thirty-two patients with limb-threatening ischemia underwent 35 infrageniculate reconstructions with a Distaflo graft between February 26, 1999, and August 24, 2000. Thirty-two of 35 bypasses were performed on extremities that had previously undergone a surgical procedure. Forty-eight previous revascularization procedures were done on these 25 extremities. Thirty grafts were constructed to the tibial outflow sites, whereas the remaining five grafts were placed to the below-knee popliteal artery. One patient died on the second postoperative day secondary to unrelated causes, and only one graft (3%) failed during the same hospitalization. Fifteen of 35 grafts (43%) remained patent 1 to 30 months later. Four patent grafts (6%) were ligated between 2 and 14 months for infectious indications. When considering the 20 failed grafts, 9 patients underwent major amputation, 5 patients remain with chronically ischemic limbs, and 6 patients underwent additional bypass grafts. Twenty-three patients (72%) maintained limb salvage. The Distaflo PTFE graft achieves promising early patency for complex infrageniculate revascularization and may be used as an alternative conduit in patients with critical limb ischemia who do not have an adequate vein for lower extremity revascularization.

Commercially available aortic stent grafts differ in construction and clinical advantage such that creating hybrid endografts by combining components from different manufacturers is sometimes useful. We describe a multicenter experience using hybrid endografts to treat patients with challenging anatomy. Hospital records and office charts were reviewed from four institutions. Hybrid endografts were defined as those with two types of covered stents in continuity to treat an abdominal aortic aneurysm (AAA). Indications for hybrid grafts were defined by type of endoleak and whether an endoleak was expected or unexpected as determined by the preoperative radiographic evaluation. Endpoints include intraoperative endoleaks, late endoleaks, change in aneurysm size, and rupture. Hybrid endografts were used to treat AAA (endovascular aneurysm repair [EVAR]) in 90 patients, representing 7.9% of the total multicenter experience. In 7 patients (7.8%), a hybrid graft construction as a secondary procedure successfully corrected a type 1 endoleak. In the remaining 83 patients (92.2%), hybrid grafts were created at the time of original EVAR to treat expected challenging anatomy or unexpected endoleaks. Hybrid endografts corrected 88 (97.8%) type 1 endoleaks, but 2 patients (2.2%) persisted with a proximal type 1 leak requiring conversion. During follow-up of 1 to 24 months, computed tomography and ultrasound surveillance, available for 73 patients (81.1%), detected one unresolved distal type 1 (1.1%) and seven type 2 (7.8%) endoleaks. Aneurysm size decreased at least 0.5 cm in 23 of 50 patients (46.0%) at 6 months and in 19 of 31 patients (61.3%) at 12 months. Aneurysm size increased at least 0.5 cm in 4 of 50 patients (8.0%) at 6 months and in 1 of 31 patients (3.2%) at 12 months. There were no ruptures. Hybrid endografts have favorable early and intermediate results in the treatment of AAA. Long-term follow-up will be needed to confirm the absence of significant adverse biomaterial interaction and the effect on AAA exclusion. We advocate the use of hybrid endografts as endovascular therapy for patients whose anatomy may be unsuitable for a single endograft type.

Objective: To evaluate the early results of endovascular grafting for high-risk surgical candidates in the treatment of abdominal aortic aneurysms (AAA)., Summary Background Data: Since the approval of endoluminal grafts for treatment of AAA, endovascular repair of AAA (EVAR) has expanded to include patients originally considered too ill for open AAA repair. However, some concern has been expressed regarding technical failure and the durability of endovascular grafts., Methods: The University of Alabama at Birmingham (UAB) Computerized Vascular Registry identified all patients who underwent abdominal aneurysm repair between January 1, 2000, and June 12, 2002. Patients were stratified by type of repair (open AAA vs. EVAR) and were classified as low risk or high risk. Patients with at least one of the following classifications were classified as high risk: age more than 80 years, chronic renal failure (creatinine > 2.0), compromised cardiac function (diminished ventricular function or severe coronary artery disease), poor pulmonary function, reoperative aortic procedure, a "hostile" abdomen, or an emergency operation. Death, systemic complications, and length of stay were tabulated for each group., Results: During this 28-month period, 404 patients underwent AAA repair at UAB. Eighteen patients (4.5%) died within 30 days of their repair or during the same hospitalization. Two hundred seventeen patients (53%) were classified as high risk. Two hundred fifty-nine patients (64%) underwent EVAR repair, and 130 (50%) of these were considered high-risk patients (including four emergency procedures). One hundred forty-five patients (36%) underwent open AAA repair, including 15 emergency operations. All deaths occurred in the high-risk group: 12 (8.3%) died after open AAA repair and 6 (2.3%) died after EVAR repair. Postoperative length of stay was shorter for EVAR repair compared to open AAA., Conclusions: High-risk and low-risk patients can undergo EVAR repair with a lower rate of short-term systemic complications and a shorter length of stay compared to open AAA. Despite concern regarding the durability of EVAR, high-risk patients should be evaluated for EVAR repair before committing to open AAA repair.

Endovascular therapies are now commonly used in many vascular sites. However, the role for carotid angioplasty and stenting (CAS) remains an unproven therapy with some potential benefits. Initial results of CAS were worse than the surgical standard of carotid endarterectomy (CEA) and did not meet American Heart Association guidelines. However, recent improvements have resulted in improved stroke morbidity rate that may approach that of CEA. Specifically, the embolic problem associated with CAS has been reduced with embolic protection devices, but the ultimate effect of these protection devices remains uncertain. Initial comparison studies of CAS to CEA showed an unacceptably high stroke morbidity rate in the CAS group. As a result, multiple randomized clinical trials have been initiated to compare the results of CAS with embolic protection to that of CEA. While these studies are underway, the authors advocate a careful application of CAS to be used as a complementary tool for the carotid surgeon to use in special circumstances when CEA cannot be undertaken with acceptable morbidity. Furthermore, since the reported stroke morbidity rate of CAS exceeds the AHA recommendation for treatment of asymptomatic patients, most nonsurgical patients with asymptomatic disease should be treated with medical therapy.

Revascularization of extracranial carotid artery stenosis (ECAS) continues to be the subject of spirited academic debate. Conflicting studies in the literature have fostered uncertainty among patients choosing between CEA and CAS. We obtained preference-based utilities from prospective patients being evaluated for ECAS and incorporated them into a decision analytic model. Patients being evaluated for ECAS in an outpatient setting were interviewed prior to their initial visit with a vascular surgeon. Patient preference data were elicited using probability trade-off (PTO) assessment and time trade-off (TTO) method. Decision analysis was performed to compare CEA with CAS. Morbidity and mortality rates were obtained from recent literature reports from the same institution. Our results showed that when patients are informed, they prefer and will more often choose CEA over CAS for revascularization of ECAS. Among patients preferring CAS, they expect no more than a 46% increase in the rate of stroke and/or death. Future clinical studies on true stroke rates for CAS will be required to further refine this analysis.

Background: Only two aortic stent grafts (Ancure-Guidant, Menlo Park, CA, and AneuRx-Medtronic, Sunnyvale, CA) have been FDA-approved for endovascular aortic aneurysm repair (EndoAAA). These grafts differ significantly in construction and clinical advantage, and combining components of these grafts (hybrid graft) is occasionally necessary. The role and outcome of hybrid aortic stent grafts is unknown., Methods: All EndoAAA procedures during an 18-month period (10/99-4/01) were reviewed using the hospital record and a computer registry. Endografts were classified as hybrid if components from more than one type of stent graft were used or standard if constructed from only one stent graft type. Hybrid grafts were further classified as "anticipated" or "unanticpated." Outcomes were compared between hybrid and standard grafts using Fisher's exact test., Results: One hundred forty-five EndoAAA repairs were performed (AneuRx, 67; Ancure, 70; and custom-made, 8) of which 14 (9.6%) were hybrid grafts. The majority of hybrid grafts (11) were constructed by adding AneuRx aortic or iliac cuffs to Ancure grafts. In most cases, the need for a hybrid graft was unanticipated (10) and related to an intraoperative proximal type I endoleak (7). Conversion to open operation was avoided in six patients by constructing hybrid grafts. When anticipated (4), hybrid grafts were constructed to treat complex iliac aneurysms. Outcomes in all categories were similar (P > 0.05) for hybrid vs standard grafts: technical success (93 vs 99%), conversion toopen AAA (7.1 vs 2.3%), vascular complications (7.1 vs 7.6%), systemic complications (21 vs 11%), endoleak (15 vs 14%), and rupture (0 vs 0%)., Conclusions: The short-term safety and effectiveness of hybrid grafts are similar to those of standard grafts. Combining graft components to create hybrid grafts may increase the ability to treat complex iliac aneurysmal disease and may reduce conversions to open AAA repair. Thus, access to multiple graft types may be an important factor in the success and safety of EndoAAA repair.

Context: Among patients with abdominal aortic aneurysm (AAA) who have high operative risk, repair is usually deferred until the AAA reaches a diameter at which rupture risk is thought to outweigh operative risk, but few data exist on rupture risk of large AAA., Objective: To determine the incidence of rupture in patients with large AAA., Design and Setting: Prospective cohort study in 47 Veterans Affairs medical centers., Patients: Veterans (n = 198) with AAA of at least 5.5 cm for whom elective AAA repair was not planned because of medical contraindication or patient refusal. Patients were enrolled between April 1995 and April 2000 and followed up through July 2000 (mean, 1.52 years)., Main Outcome Measure: Incidence of AAA rupture by strata of initial and attained diameter., Results: Outcome ascertainment was complete for all patients. There were 112 deaths (57%) and the autopsy rate was 46%. Forty-five patients had probable AAA rupture. The 1-year incidence of probable rupture by initial AAA diameter was 9.4% for AAA of 5.5 to 5.9 cm, 10.2% for AAA of 6.0 to 6.9 cm (19.1% for the subgroup of 6.5-6.9 cm), and 32.5% for AAA of 7.0 cm or more. Much of the increased risk of rupture associated with initial AAA diameters of 6.5-7.9 cm was related to the likelihood that the AAA diameter would reach 8.0 cm during follow-up, after which 25.7% ruptured within 6 months., Conclusion: The rupture rate is substantial in high-operative-risk patients with AAA of at least 5.5 cm in diameter and increases with larger diameter.

Background: The French paradox has been associated with regular intake of red wine, which is enriched with flavonoids. Quercetin, a flavonoid present in the human diet, exerts cardiovascular protection through its antioxidant properties. We hypothesized that the beneficial effect of quercetin also could be related to the inhibition of vascular smooth muscle cell proliferation and migration., Methods: Human aortic smooth muscle cells (AoSMC) were grown in culture in the presence of serum. Quercetin inhibited the serum-induced proliferation of AoSMC. This inhibition was dose-dependent and not attributed to toxicity. Cell cycle analysis revealed that quercetin arrested AoSMC in the G(0)/G(1) phase. The effect of quercetin on AoSMC migration was examined using explant migration and Transwell migration assays. Quercetin significantly decreased migration in both assays in a consistent manner. Finally, Western blot analysis of AoSMC exposed to quercetin demonstrated a significant reduction in the activation of mitogen-activated protein kinase, a signaling pathway associated with the migration of vascular smooth muscle cells., Conclusions: Quercetin inhibits the proliferation and migration of AoSMC, concomitant with inhibition of mitogen-activated protein kinase phosphorylation. These findings provide new insights and a rationale for the potential use of quercetin in the prophylaxis of cardiovascular diseases.

Background: Carotid angioplasty and stenting is under investigation in clinical trials as an alternative to endarterectomy. Some clinicians have hypothesized that stenting would be applicable for patients at high risk who need carotid revascularization. To further test this hypothesis, we stratified our carotid endarterectomy procedures according to current carotid stent protocols., Methods: We reviewed our computerized registry and the clinical charts of patients who underwent carotid endarterectomy. Each procedure was categorized as high risk or low risk, according to the following six separate high-risk factors: 1, severe cardiac dysfunction; 2, the requirement for combined coronary and carotid vascularization; 3, severe pulmonary dysfunction; 4, contralateral internal carotid artery occlusion; 5, previous ipsilateral carotid endarterectomy; and 6, anatomically limited access for carotid endarterectomy. Rates of stroke at 30 days, cardiac complications, and death were tabulated., Results: Between January 1, 1998, and December 31, 2000, 415 carotid endarterectomies were performed on 389 patients. Ninety-eight procedures (23.6%) were classified as high risk on the basis of the following factors: 1, severe cardiac dysfunction (n = 30); 2, requirement for combined coronary and carotid revascularization (n = 14); 3, severe pulmonary dysfunction (n = 8); 4, contralateral carotid occlusion (n = 31); 5, previous ipsilateral carotid endarterectomy (n = 25); and 6, anatomically limited access (n = 4). Seven patients had ipsilateral postoperative strokes (1.7%), with two additional patients having contralateral hemispheric strokes. One patient died from exacerbation of congestive heart failure 9 days after undergoing a second carotid endarterectomy. The total stroke and death rate was 2.6% for all the patients. Two of the 98 procedures in the high-risk group were complicated with ipsilateral stroke (2.0%) as compared with six of the 317 low-risk procedures (1.9%; P = 1). Six procedures were complicated with cardiac dysfunction after surgery, including myocardial infarction, congestive heart failure, or the new onset of atrial fibrillation. Three cardiac complications occurred in the low-risk group (1%), and three occurred in the high-risk group (3.1%; P =.15)., Conclusion: This series shows that patients at high risk can undergo carotid endarterectomy with stroke rates equivalent to the rates of patients at low risk. The cardiac morbidity rate may be increased in the high-risk group. Carotid stenting is unlikely to offer any improvement in stroke risk as compared with carotid endarterectomy, but stenting may reduce non-stroke morbidity rates associated with some high-risk cases.

Background: Endoscopic saphenous vein harvest has been explored as a minimally invasive alternative to a long continuous leg incision for removal of the greater saphenous vein. The endoscopic technique uses limited incisions (2-4) with extended "skin bridges" and videoscopic equipment for the dissection and removal of the greater saphenous vein. This study was undertaken to evaluate the long-term durability of saphenous vein grafts harvested by an endoscopic technique and used for lower extremity arterial revascularization., Methods: All patients who underwent endoscopic saphenous vein harvesting for lower extremity arterial bypass grafting were prospectively followed for graft patency and risk factors. Grafts were surveyed with serial duplex scans at 3- to 6-month intervals over this 5-year study. Life-table methods were used to assess graft survival. A computerized registry and medical records were reviewed to determine graft patency and patient survival., Results: From September 1994 to August 2000, 164 lower extremity arterial saphenous vein grafts harvested by an endoscopic technique were used for lower extremity arterial bypass grafting in 150 patients. The patient population included 111 males (75%) and 112 smokers (75%), but also included a high-risk cohort of 65 diabetic patients (43%) and 15 patients undergoing dialysis/renal transplant (10%). Twenty-eight patients (19%) died within the study period. With life-table methods, 1-, 3-, and 5-year secondary patency rates were 85% (+/- 3.2%), 74% (+/- 5.7%), and 68% (+/- 11.6%). Of the 30 failed grafts, 7 (4%) failed in the first month related to inadequate runoff (4), cardiac instability (2), and an additional surgical procedure (1). Twenty-three grafts (14%) failed between 1 and 42 months. Twenty-two (16%) of these 134 patent grafts underwent a second procedure to maintain patency (13 as primary-assisted patency and 9 as secondary patency)., Conclusions: Endoscopic saphenous vein harvest for lower extremity arterial reconstruction provides a satisfactory conduit for lower extremity bypass grafting. Although increased manipulation from this limited access technique may incite an injury response in the vein, these vein grafts can maintain an adequate patency for lower extremity bypass grafting.

Blunt abdominal aortic trauma occurs in up to 0.04% of all nonpenetrating traumas. Although uncommon, mortality from this injury ranges from 18% to 37%. Seat belt injury is associated with almost 50% of reported blunt abdominal aortic traumas. The authors present the case of a 21-year-old man, a restrained passenger who was involved in a high-speed motor vehicle accident. In the emergency room, he had obvious evidence of lap-belt injury. His peripheral pulses were normal and there was no pulsatile abdominal mass. Computer tomography (CT) revealed a large amount of free intraperitoneal fluid throughout with signs of mesenteric avulsion and fracture/dislocation of T11-T12. The patient underwent an exploratory laparotomy. Right hemicolectomy and resection of small bowel was performed. CT angiography revealed an aortic transection and surrounding pseudoaneurysm 2 cm above the aortic bifurcation. The patient returned to the operating room for endovascular repair. Via a right femoral cutdown, a 14 mm x 5.5 cm stent-graft was placed across the distal abdominal aorta. Follow-up arteriogram revealed complete obliteration of the pseudoaneurysm without evidence of leak. There were no complications related to the aortic stent-graft in the postoperative period. The patient was discharged in good condition. As this case demonstrates, endovascular repair of traumatic aortic injury is feasible and may represent an improved treatment in certain settings.

Saphenous vein harvest is a necessary step in many cardiac and peripheral vascular reconstructions. However, saphenectomy is not inconsequential and can lead to short- and long-term morbidity. To avoid the morbidity, new technology has been developed to remove the saphenous vein with limited incisions using video-assisted, or endoscopic, techniques. Although a number of manufacturers have developed equipment for this purpose, we have developed expertise with the Ethicon Endo-Surgery (Cincinnati, OH) system. We have used this technique for more than 100 lower-extremity bypass operations with minimal wound complications and satisfactory revascularization. The technical features of this operation are presented.

Unlabelled: Microemboli, as detected by transcranial Doppler monitoring, have been shown to be a potential cause of strokes after carotid endarterectomy. We retrospectively reviewed 105 patients who underwent transcranial Doppler monitoring during 112 procedures for the treatment of 115 carotid bifurcation stenoses: 40 by percutaneous angioplasty with stenting and 75 by carotid endarterectomy. In PTAS procedures (n = 40), there was a mean of 74.0 emboli per stenosis (range 0-398, P = 0.0001) with 4 neurologic events per patient (P = 0.08). In CEA procedures (n = 76), there was a mean of 8.8. emboli per stenosis (range 0-102, P= 0.0001) with 1 neurologic event per patient (P = 0.08). The post-procedural neurological events in the percutaneous angioplasty with stenting population included two strokes (5.6%) and two transient ischemia attacks (5.6%). Microemboli for each of these cases totalled 133, 17, 29 and 47 (with one shower), respectively. One postoperative carotid endarterectomy patient was noted to have a stroke (1.4%), with 48 microemboli noted during that procedure. The mean emboli rate for percutaneous angioplasty with stenting patients with neurological events was 59.0: without complications it was 85.1. The mean emboli rate for carotid endarterectomy patients without complications was 8.3. Three percutaneous angioplasty with stenting patients had no emboli (7.5%), whereas 29 carotid endarterectomy patients had no emboli (38.7%)., Conclusion: The percutaneous angioplasty with stenting procedure is associated with more than eight times the rate of microemboli seen during carotid endarterectomy when evaluated with transcranial Doppler monitoring. Larger patient groups are needed to determine if this greater embolization rate has an associated risk of higher morbidity or mortality.

Abdominal aortic aneurysms (AAAs) are the 13th leading cause of death in the United States. Endovascular stent grafts are currently being investigated in clinical trials as an alternative method for treatment of AAA. Twelve pigs underwent creation of AAA using the abdominus rectus fascia. Postoperatively, all 12 animals underwent angiography, which demonstrated turbulent flow within the created aneurysms. Four of the animals were not stented and served as controls. Eight animals underwent subsequent percutaneous placement of a covered endovascular stent via a right femoral sheath, and the stents were deployed between the renal arteries and the aortic bifurcation. The animals were maintained for 120 days before sacrifice and necropsy. Unstented animals (4) died within 6 days, 3 from rupture. Eight animals underwent endovascular stenting: 5 survived without complications, 3 deaths within 2 days were related to technical complications. The 5 surviving animals were sacrificed at 120 days, and necropsy was conducted with in situ dissections of the aorta and intact stent: 3 experimental animals had correct anatomic positioning of the stent, and 2 had inexact stent placement but survived 120 days with AAA thrombosis. Treatment of AAA in this swine model has been demonstrated via placement of a percutaneous covered stent.

Background: Carotid angioplasty with stenting (PTAS) is now being investigated as an alternative to carotid endarterectomy (CEA). Proven superiority in at least three areas of PTAS will need be accomplished before angioplasty supplants CEA; namely, safety, cost, and durability., Methods: One hundred and seven patients served as the basis for this previously reported review. Both safety (morbidity and mortality) as well as cost issues were evaluated. Other non-neurologic complications were are also investigated., Results: The in-hospital and 30-day risk of all strokes and death from PTAS was 9.3%, with a 3.6% major stroke and death rate. Minor strokes were found to be statistically more frequent in the PTAS group than with CEA. Nonprofessional fees were more expensive in the PTAS group than CEA ($30,140 versus $21,670)., Conclusions: At the present time PTAS has not proven itself worthy to supplant CEA. The durability of the procedure has not been sufficiently evaluated. Non-neurologic complications are also not trivial with PTAS.

Introduction: Percutaneous transluminal angioplasty with stenting (PTAS) has been considered a potential alternative to carotid endarterectomy (CEA) for stroke prevention. Interventionalists have suggested that PTAS carries less anesthetic risk than CEA. The treatment of carotid stenosis with local or regional anesthesia (LRA) allows direct intraprocedural neurologic evaluation and avoids the potential risks of general anesthesia., Methods: We retrospectively analyzed the clinical charts of 377 patients who underwent 414 procedures for the elective treatment of carotid stenosis in 433 cerebral hemispheres with LRA between August 1994 and May 1997. Group I (312 hemispheres) underwent PTAS, and group II (121 hemispheres) underwent CEA., Results: The indications for treatment included the following: asymptomatic severe stenosis (n = 272; 62.8%), transient ischemic attack (TIA; n = 100; 23.1%), and prior stroke (n = 61; 14.1%). The early neurologic results for the patients in group I (n = 268) included 11 TIAs (4.1%), 23 strokes (8.6%), and 3 deaths (1.1%). The early neurologic results for the patients in group II (n = 109) included 2 TIAs (1.8%), one stroke (0.9%), and no deaths. The total stroke and death rates were 9.7% for the patients in group I and 0.9% for the patients in group II (P = .0015). The cardiopulmonary events that led to additional monitoring were evident after 96 procedures in group I (32.8%) and 21 procedures in group II (17.4%; P = .002)., Conclusion: PTAS carries a higher neurologic risk and requires more monitoring than CEA in the treatment of patients with carotid artery stenosis with LRA. The proposed benefit for the use of PTAS to avoid general anesthesia cannot be justified when compared with CEA performed with LRA.

Purpose: Percutaneous transluminal angioplasty with stenting (PTAS) of the carotid artery has been advocated as an alternative treatment for high-grade stenosis. Rationale for this approach includes less morbidity, shorter recovery, and lower cost when compared with carotid endarterectomy (CEA)., Methods: The clinical results and hospital charges of patients who underwent elective treatment for carotid stenosis were reviewed. During a concurrent 14-month period, 218 patients were admitted 229 times for 234 procedures for the treatment of 239 carotid bifurcation stenoses, 109 by PTAS and 130 by CEA. Hospital charges were reviewed for each hospitalization and were categorized according to radiology, operating room, cardiac catheterization laboratory, and all other hospital charges., Results: The combined incidence of postprocedure strokes and deaths were: PTAS, eight strokes (7.7%) and one death (0.9%); CEA, two strokes (1.5%) and two deaths (1.5%). Total hospital charges per admission for the two groups were $30,140 for PTAS and $21,670 for CEA. The average postprocedure length of stay for PTAS was 2.9 days (median, 2 days) and for CEA was 3.1 days (median, 3 days). Cardiac catheterization laboratory charges for the PTAS group were $12,968, whereas the operating room charges for the CEA group were $4263. When hospitalizations that were extended by complications were excluded, the average total charges for the PTAS group (n = 84) dropped to $24,848 (mean length of stay, 1.9 days) and for the CEA group (n = 111) to $19,247 (mean length of stay, 2.6 days)., Conclusions: After evaluating hospital charges, PTAS for the treatment of carotid stenosis cannot currently be justified on the basis of reduced costs alone. With future cost-containing measures, total hospital charges can be reduced in both groups.

Carotid endarterectomy (CEA) is the treatment of choice for asymptomatic and symptomatic disease causing greater than 60% internal carotid artery (ICA) stenosis. Recently, percutaneous transluminal angioplasty (PTA) with stent placement has been investigated as a therapeutic option for the treatment of ICA stenosis. In this report the authors document CEA performed after PTA with stent placement and describe the pathological findings. A standard CEA was performed. The surgical intervention was more difficult secondary to the following variables: the length of the exposure necessary to dissect out the metallic stent, the difficulty with opening and cutting the artery, and the care required to remove the stent to avoid vessel wall perforation. Pathological examination of the specimen demonstrated classic atherosclerotic changes revealing persistence of native disease. The metallic stent was embedded within the plaque. Many questions remain unanswered regarding the physiological and biological changes that occur in the carotid vessel wall after PTA with stent placement. It is concluded that CEA of a stent-containing carotid artery is feasible and should be considered as an alternative when recurrent stenosis occurs after PTA.

Purpose: Saphenous vein harvesting remains a significant source of morbidity that occurs in 1% to 24% of patients who require lower extremity bypass or coronary artery bypass grafting. In an attempt to reduce complications associated with this procedure, we have used a new, minimally invasive technique to remove the greater saphenous vein., Methods: The video-assisted technique uses currently available video-endoscopic equipment with mechanical retraction to dissect the saphenous vein with two to three limited incisions. After initial vein exposure is accomplished through limited incisions, mechanical retraction is maintained with an endoplastic retractor or an endoscopic saphenous vein retractor. The dissection is visualized on the video monitor to isolate and control side branches, the vein is removed, and arterial bypass grafting is then accomplished as a reverse vein graft., Results: Between Sep. 1994 and July 1996, 65 patients underwent 68 arterial bypass operations in which the greater saphenous vein was harvested with video-assisted techniques. Indications for bypass grafting included 31 patients with ischemic ulceration, 23 with rest pain, 11 with claudication, and three with popliteal aneurysms. Of the 68 bypass procedures performed, 52 were to below-knee vessels, 22 of which included tibial or peroneal anastomoses. Sixty-four patients (98.5%) had no significant complications related to this video-assisted technique. For all patients, the average time-required to remove a 45 cm vein segment was 60 minutes. The average time using the more recently developed endoscopic saphenous vein retractor was 46 minutes. The median postoperative length of stay was 6 days. One patient had bleeding into the leg related to the video-assisted technique. Three patients (4.4%) required rehospitalization for wound care related to arterial access sites. Patency has been confirmed in 84% of grafts followed-up for a range of 1 to 24 months., Conclusions: In this report representing a series of unselected patients, video-assisted saphenous vein harvesting was technically feasible and had no immediate contraindications. The greater saphenous vein can be removed with minimally invasive techniques, leading to an acceptable morbidity rate, and is a satisfactory conduit for arterial bypass procedures. A prospective clinical trial may be justified to further evaluate the use of this technique in decreasing postoperative morbidity rates, shortening hospitalization, and improving patient care.

Background: Surgical endarterectomy has been shown to be superior to medical management in the management of severe carotid stenosis in both symptomatic and asymptomatic patients. Endarterectomy, although effective, does have limitations, and percutaneous techniques may offer an alternative method of treatment., Methods and Results: The feasibility and safety of percutaneous carotid angioplasty and elective (primary) stenting was evaluated prospectively in a consecutive series of 107 patients. One hundred twenty-six carotid arteries with significant stenosis were treated. This series represented a high-risk subset that included patients with previous ipsilateral endarterectomy and severe medical comorbidity. Forty-five percent of the patients were referred by surgeons. Patients had independent neurological examinations before and after the procedure and follow-up cerebral angiography at 6 months. The mean (+/- SD) stenosis was reduced from 78 +/- 14% to 2 +/- 5%. There were 7 minor strokes, 2 major strokes, and 1 death during the initial hospitalization and first 30 days after the procedure. For the combined end point of all strokes and death, the incidence was 7.9%. For ipsilateral major stroke and death, the incidence was 1.6%. There were no strokes during the follow-up period. Mean angiographic stenosis at 6 months in 81 patients was 18 +/- 16% (range, -21% to 57%). Four (4.9%) of these 81 patients had asymptomatic restenosis. Five asymptomatic patients had repeat intervention: 2 had angioplasty for restenosis, 2 had angioplasty for stent deformation, and 1 had endarterectomy for restenosis., Conclusions: In a high-risk group of patients, percutaneous carotid angioplasty and stenting are feasible and can be performed with low restenosis and repeat intervention rates.

Carotid endarterectomy has been established as the standard treatment for high-grade carotid stenosis. The results of an ongoing prospective trial for the safety of percutaneous angioplasty with stenting (PTAS) were compared to retrospectively reviewed patients treated with carotid endarterectomy (CEA). During the same 14-month period, 273 patients underwent treatment of 310 carotid bifurcation stenoses: 107 by PTA with stenting, 166 by CEA. Indications for treatment included stroke 46 (16.8%), transient ischemic attack 109 (39.9%), syncope 7 (2.6%), and high-grade asymptomatic stenosis 111 (40.7%). Combined early stroke and death rates are listed as follows: [table: see text] Important nonneurologic complications were evident in six (5.6%) PTAS patients and two (1.2%) CEA patients. Six-month follow-up data was available for 193 patients (71%) with the following results: seven (6.5%) minor strokes in the PTAS group, one (0.6%) minor stroke in the CEA group, one (0.9%) major stroke in the PTAS group, one (0.6%) major stroke in the CEA group, four deaths (3.7%) in the PTAS group, and six deaths (3.6%) in the CEA group. Early results from PTA with stenting are promising but not safer than CEA for the treatment of carotid artery stenosis. Long-term follow-up is needed to determine the ultimate durability of this new technique. PTA with stenting may be an alternative for the treatment of carotid bifurcation lesions in selective high-risk surgical patients.

Harvest of the saphenous vein is a commonly performed procedure in cardiovascular surgery. The incision required for its removal is the longest used anywhere. In this report, the authors describe a minimally invasive technique for removal of the vein. This has been used in 30 patients undergoing peripheral arterial bypass (n = 27), venovenous bypass (n = 2), and a saphenopopliteal fistula (n = 1). There were three perioperative complications: skin necrosis over tunnel (one), bulla (one), and saphenous vein injury (one). Harvest time averaged 1.25 h. There was minimal postoperative discomfort in the harvest site and minimal scarring. Endoscopic harvest of the saphenous vein differs from most laparoscopic procedures because of its linear course. Consequently, visualization and dissection is coaxial rather than triangulation. This study demonstrates the technical feasibility of vein harvest. Development of appropriate instrumentation for opening the optical cavity and vein manipulation will reduce operative times.

Nephrectomy and revascularization are currently the preferred options in the management of the chronically occluded renal artery in patients with renovascular hypertension or renal insufficiency. We review our experience with these two options including early and late functional outcome. Between December 1982 and August 1993, chronic occlusion of the main renal artery was documented in 30 patients. Patients were categorized with respect to surgical intervention: group I underwent nephrectomy (on the occluded side) plus contralateral revascularization and group II underwent revascularization of the occluded renal artery. The median age at the time of operative intervention was 63 years; 53% of the patients were women and 47% were men. Hypertension was poorly controlled (> or = 3 medications) in 19 patients, and the preoperative serum creatinine level was > 1.8 mg/dl in 24 patients (mean 2.6 +/- 1.4 mg/dl). There were 16 patients in group I and 14 patients in group II, and there were no perioperative deaths. Estimated glomerular filtration rate (> or = 7 days after operation) was either unchanged or improved in 15 of 16 patients in group I and in 13 of 14 in group II, one of whom became dialysis dependent. Follow-up data were available for 25 of 30 (83%) patients (mean 45 months; range 1 to 108 months). Excluding one early failure, 10 of 13 patients in group I and 7 of 11 in group II did not have end-stage renal disease at last follow-up. Overall, hypertension was cured or improved in 16 of 21 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

To our knowledge, a particularly lethal complication of carotid endarterectomy, intracerebral hemorrhage, has not been given due consideration in the literature concerning carotid surgery. In the Atlanta area, massive intracranial hemorrhage developed in ten patients following routine carotid endarterectomies performed during a recent ten-year period. All ten of the patients in this series died despite a variety of therapeutic interventions. Risk factors may include the following: extreme arterial stenosis with resultant postoperative hyperperfusion, involvement of multiple extracranial cerebral vessels, postoperative systemic hypertension, and administration of anticoagulant or antiplatelet medications. Unfortunately, identification of the subset of patients potentially at risk for this complication is difficult, and, to date, therapy has been generally ineffective.