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Purpose: The purpose of this study was to determine the safety and durability of traditional surgical treatment for asymptomatic infrarenal abdominal aortic aneurysms (AAAs) in a large series of patients who underwent open operations during the decade preceding the commercial availability of stent graft devices for endovascular AAA repair., Methods: From 1989 to 1998, 1135 consecutive patients (985 men [87%], 150 women; mean age, 70 +/- 7 years) underwent elective graft replacement of infrarenal AAA. Computerized perioperative data have been supplemented with a retrospective review of hospital charts/outpatient records and a telephone canvass to calculate survival rates and the incidence rate of subsequent graft-related complications. Seventy-four patients (6.5%) were lost during a median follow-up period of 57 months for the entire series., Results: The 30-day mortality rate was 1.2%. The hospital course was completely uneventful for 939 patients (83%), and the median length of stay for all patients was 8 days. A total of 196 patients had single (n = 150; 13%) or multiple (n = 46; 4%) postoperative complications, which were more likely to occur in men (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.1 to 5.2) and in patients with a history of congestive heart failure (OR, 3.7; 95% CI, 1.7 to 7.8), chronic pulmonary disease (OR, 1.9; 95% CI, 1.2 to 2.9), or renal insufficiency (OR, 2.5; 95% CI, 1.3 to 4.7). Kaplan-Meier method survival rate estimates were 75% at 5 years and 49% at 10 years. As was the case with early complications, the long-term mortality rate primarily was influenced by age of more than 75 years (risk ratio [RR], 2.2; 95% CI, 1.7 to 2.8) or previous history of congestive heart failure (RR, 2.1; 95% CI, 1.3 to 3.4), chronic pulmonary disease (RR, 1.5; 95% CI, 1.2 to 2.0), or renal insufficiency (RR, 3.2; 95% CI, 2.2 to 4.6). Of the 1047 patients who survived their operations and remained available for follow-up study, only four (0.4%) have had late complications that were related to their aortic replacement grafts., Conclusion: These results reconfirm the exemplary success of open infrarenal AAA repair. The future of endovascular AAA repair is exceedingly bright, but until the long-term outcome of the current generation of stent grafts is adequately documented, their use should be justified by the presence of serious surgical risk factors.

Purpose: We documented the postoperative complication rate and the late results of simultaneous infrarenal aortic replacement and renal artery (RA) revascularization at the Cleveland Clinic and correlated these findings with the preoperative serum creatinine level (S(Cr)) and other baseline risk factors., Methods: A retrospective review of hospital charts and outpatient records was supplemented with a telephone canvass and the invitation to return for a complimentary RA duplex scan, when a scan had not been done within the previous year. Data were collected for 73 consecutive patients (mean age, 69 years) who underwent aortic procedures that were combined with the repair of RA stenosis from 1989 to 1997 (mean follow-up, 44 months). The preoperative S(Cr) was 2 mg/dL or lower in 45 patients (group R1; median, 1.5 mg/dL) and was higher than 2 mg/dL in the remaining 28 patients (group R2; median, 2.6 mg/dL)., Results: Forty-seven of the patients in this series had aortic aneurysms, 15 patients had aortoiliac occlusive disease, and 11 patients had both types of lesions. Bilateral RA revascularization was necessary for seven patients in group R1 (15%) and for eight patients in group R2 (29%). Group R2 contained more patients with medically resistant hypertension (57%) than group R1 (29%, P = .019). Although there was no statistically significant difference between the 30-day mortality rates (group R1, 2.2%; group R2, 11%), the related in-hospital mortality rate for 15 bilateral RA revascularizations (13%) was nearly twice that of 58 unilateral revascularizations (6.9%). Patients in group R2 were at a higher risk for postoperative dialysis than those in group R1 (36% vs 6.7%, P = .008), and patients in group R2 had longer lengths of stay in the hospital (median, 14 days vs 9 days; P = .004). By means of Kaplan-Meier analysis, the 5-year survival rate was lower for patients in group R2 (53%; 95% CI, 33%-73%) than for patients in group R1 (85%; 95% CI, 74%-96%; log rank P = .005). Despite all other liabilities in group R2 patients, however, their resistant hypertension was cured or improved in 88% of cases and their S(Cr) appeared to decline with time., Conclusion: The early postoperative risk of simultaneous aortic/RA procedures appears to be highest in patients who have an elevated S(Cr), bilateral RA stenosis or occlusion, and a comparatively low long-term survival rate. In this particular group, the adjunctive use of endovascular techniques might conceivably reduce the magnitude of the planned surgical procedure and thus enhance the overall outcome.

Purpose: This study was undertaken to determine the safety and efficacy of reoperations for recurrent carotid stenosis (REDOCEA) at the Cleveland Clinic., Materials and Methods: From 1989 to 1999, 206 consecutive REDOCEAs were performed in 199 patients (131 men, 68 women) with a mean age of 68 years (median, 69 years; range, 47-86 years). A total of 119 procedures (57%) were performed for severe asymptomatic stenosis, 55 (27%) for hemispheric transient ischemic attacks or amaurosis fugax, 26 (13%) for prior stroke, and 6 (3%) for vertebrobasilar symptoms. Eleven REDOCEAs (5%) were combined with myocardial revascularization, and another 19 (9%) represented multiple carotid reoperations (17 second reoperations and 2 third reoperations). Three REDOCEAs (1%) were closed primarily, and nine (4%) required interposition grafts, whereas the remaining 194 (95%) were repaired with either vein patch angioplasty (139 [68%]) or synthetic patches (55 [27%]). Three patients (2%) were lost to follow-up, but late information was available for 196 patients (203 operations) at a mean interval of 4.3 years (median, 3.9 years; maximum, 10.2 years)., Results: Considering all 206 procedures, there were 7 early (< 30 days) postoperative neurologic events (3.4%), including 6 perioperative strokes (2.9%) and 1 occipital hemorrhage (0.5%) on the 12th postoperative day. Seventeen additional neurologic events occurred during the late follow-up period, consisting of eight strokes (3.9%) and nine transient ischemic attacks (4.4 %). With the Kaplan-Meier method, the estimated 5-year freedom from stroke was 92% (95% CI, 88%-96%). There were two early postoperative deaths (1%), both from cardiac complications after REDOCEAs combined with myocardial revascularization procedures. With the Kaplan-Meier method, the estimated 5-year survival was 81% (range, 75%-88%). A univariate Cox regression model yielded the presence of coronary artery disease as the only variable that was significantly associated with survival (P =.024). The presence of pulmonary disease (P =.036), diabetes (P =.01), and advancing age (P =.006) was found to be significantly associated with stroke after REDOCEA. Causes of 53 late deaths were cardiovascular problems in 25 patients (47%), unknown in 14 (26%), renal failure in 4 (8%), stroke in 3 (6%), and miscellaneous in 7 (13%)., Conclusions: We conclude that REDOCEA may be safely performed in selected patients with recurrent carotid stenosis and that most of these patients enjoy long-term freedom from stroke.

Purpose: Given the uncertainties associated with carotid angioplasty and stenting, the initial assessment of the procedure may be best undertaken in a subgroup of patients at increased risk for complications with standard carotid surgery. In an effort to characterize such a subgroup, we reviewed the results of carotid endarterectomy in patients with and without significant medical comorbidity., Methods: During a 10-year period 3061 carotid endarterectomies were performed at a single institution and entered prospectively into a registry. A high-risk patient subgroup was identified, defined by the presence of severe coronary artery disease, chronic obstructive lung disease, or renal insufficiency. The outcome of carotid endarterectomy was assessed with respect to perioperative stroke, myocardial infarction, or death, as well as the combined end point of one or more of the end points., Results: The rate of the composite end point stroke/myocardial infarction/death was 3.8% in the total group of 3061 patients who underwent endarterectomy. As individual end points, the rate of stroke was 2.1%, myocardial infarction 1.2%, and death 1.1%. Among the high-risk subset, the composite end point stroke/myocardial infarction/death occurred in 7.4%. This rate was significantly greater than the corresponding rate of 2.9% in the low-risk subset (P <.0005). Similarly, the rate of stroke (3.5% vs 1.7%, P =.008) or death (4.4% vs 0.3%, P <.001) as solitary events was significantly greater in high-risk patients., Conclusions: Although carotid endarterectomy is an extremely safe procedure in most patients, results are not as favorable in a high-risk subset with severe coronary, pulmonary, or renal disease. The initial clinical evaluation of carotid stenting might best be undertaken in such a high-risk population, one that comprises patients for whom standard therapy is associated with a high rate of complications.

Objective: The aim of the study was to evaluate the safety and efficacy of percutaneous angioplasty and stenting (PAS) in comparison with traditional open surgical (OS) revascularization for the treatment of chronic mesenteric ischemia., Methods: Over a 3.5-year period, 28 patients (32 vessels) underwent PAS (balloon angioplasty alone, 5 [18%] of 28; angioplasty and stenting, 23 [82%] of 28) for symptoms of chronic mesenteric ischemia. These patients were compared with a previously published series of 85 patients (130 vessels) treated with OS (bypass grafting, 60 [71%] of 85; transaortic endarterectomy, 19 [22%] of 85; or patch angioplasty, 6 [7%] of 85)., Results: The PAS and OS groups were similar with respect to baseline comorbidities, duration of symptoms (median: 6.7 vs 10.5 months, P =.52), and the number of vessels involved, but the patients differed in their age at presentation (median: 72 vs 65 years, P =.005). Fewer vessels were revascularized per patient in the PAS group (1.1 +/- 0.4) compared with the OS group (1.5 +/- 0.6, P =.001). Overall, 85.7% (24/28) had one vessel and 14.3% (4/28) had two vessels revascularized in the PAS group versus 48.2% (41/85) with one-vessel and 47.1% (40/85) with two-vessel revascularization in the OS group. No difference was noted in the early in-hospital complications (median: 17.9% [PAS] vs 32.9% [OS], P =.12) or mortality rate (10.7% [PAS] vs 8.2% [OS], P =.71). A reduced length of hospital stay in the PAS patients did not attain statistical significance (median: 5 days [PAS] vs 13 days [OS], P =.08). Although the 3-year cumulative recurrent stenosis (P =.62) and mortality rate (P =.99) did not differ, the PAS treatment group had a higher incidence of recurrent symptoms (P =.001)., Conclusion: Although the results of PAS and OS were similar with respect to morbidity, death, and recurrent stenosis, PAS was associated with a significantly higher incidence of recurrent symptoms. These findings suggest that OS should be preferentially offered to patients deemed fit for open revascularization.

From 1995 through 1998, we encountered eight patients with infected Dacron patches after previous carotid endarterectomy. Two of the original operations had been done elsewhere, but the six patients who were collected from our own series represented 0.5% of the 1258 carotid endarterectomies we performed and 1.8% of the 340 synthetic carotid patches we applied without any comparable infections among another 918 patients who received either vein patch angioplasty (n = 843) or primary arteriotomy closure (n = 74) during the same 4-year study period. With a single exception ("no growth"), bacterial cultures that were obtained at the time of the eight reoperations revealed Staphylococcus (n = 4) or Streptococcus (n = 3) species. All of the infected Dacron patches were removed and were replaced with saphenous vein patches (n = 5) or interposition grafts (n = 3), after which appropriate oral (n = 2) or intravenous (n = 6) antibiotics were administered for 2 to 6 weeks. No postoperative deaths occurred, but there were 2 temporary cranial nerve injuries, 1 myocardial infarction, and 1 stroke that was related to preoperative angiography. A recurrent carotid infection has not developed in any of the eight patients during a mean follow-up interval of 16 months (range, 3-36 months).

Objective: The purpose of this study is to review our experience with surgical repair of lower thoracoabdominal and suprarenal aortic aneurysms to determine early and late survival rates and identify factors influencing morbidity and survival among these patients., Materials: From 1989 through 1998, 165 consecutive patients underwent repair of 108 thoracoabdominal (55 group III and 53 group IV) and 57 suprarenal aneurysms. The study group consisted of 109 men and 56 women with a mean age of 70 years (median, 70 years; range, 29-89 years). Mean aneurysm diameter was 6.9 cm (median, 6.5 cm; range, 4-12 cm). There were 125 aneurysms (76%) repaired electively; 40 repairs (24%) were nonelective. The cause of 12 aneurysms (7%) was chronic aortic dissection; the remaining 153 (93%) were degenerative aneurysms., Results: The early postoperative (30-day) mortality rates were 7% (9/125) for elective and 23% (9/40) for nonelective operations (P =.016). For both elective and urgent procedures, early mortality was 1.8% (1/57) for suprarenal aneurysm repair, 11% (6/53) for group IV thoracoabdominal aneurysms, and 20% (11/55) for group III thoracoabdominal aneurysms (P =.013, suprarenal vs group III). Spinal cord ischemia occurred after 6% (10/165) of aneurysm repairs (4% paraplegia, 2% paraparesis). None of the 57 suprarenal aneurysm repairs were complicated by spinal cord ischemia, whereas it occurred in 2% (1/53) of group IV thoracoabdominal aneurysms and 16% (9/55) of group III thoracoabdominal aneurysms (P =.001, suprarenal vs group III; P =. 016, group IV vs group III). Three (25%) of the 12 patients with dissection developed spinal cord ischemia; this compared with seven (5%) of 153 patients with degenerative aneurysms (P =.027). The cumulative 3-year survival rate for the entire series was 71% (95% CI, 64%-79%), and 5-year survival was 50% (95% CI, 40%-60%)., Conclusions: Aneurysms involving the suprarenal, visceral, and lower thoracic aorta may be repaired with acceptable perioperative mortality and late survival rates. The risk of spinal cord ischemia is increased for patients with aortic dissection and may be stratified according to the proximal extent of the aneurysm.

Purpose: In an earlier report of our database for 1924 isolated carotid endarterectomies (CEAs) from 1989 to 1995, multivariable analysis results indicated that the urgency of operation unfavorably influenced the combined stroke and mortality rate (CSM). This study was conducted in an attempt to document the features that contribute to perioperative complications and late outcome in 314 patients for whom CEA was considered to be nonelective because of the severity of previous symptoms, carotid stenosis, or medical comorbidities., Methods: All the hospital charts and outpatient records were reviewed retrospectively for the 209 men and 105 women who had undergone nonelective CEAs (median age, 69 years). Information regarding the clinical risk factors, the operative indications (CHAT classification), the severity and distribution of carotid disease, and the surgical management were analyzed to assess the impact on the 30-day CSM and on the long-term survival rate and neurologic events during a median follow-up period of 34 months., Results: Previous symptoms had occurred in 285 patients (91%) and included cortical transient ischemic attacks in 47%, amaurosis fugax in 20%, completed strokes in 14%, unstable strokes in 2%, and nonspecific or miscellaneous symptoms in 8%. Preoperative angiography was performed in 308 patients (98%), which confirmed the presence of 80% to 99% ipsilateral carotid stenosis in 79% of the patients and >90% stenosis in 43%. The median interval between presentation and surgical treatment was 2 days, but 48% of the 314 CEAs were performed within 24 hours of presentation. The 30-day CSM was 6.7% and ranged from 3.4% for 29 patients with severe asymptomatic carotid stenosis to 14% for those patients with unstable strokes. The cardiac and pulmonary risk factors were the only variables that were related statistically to the CSM. During the follow-up period, the risk for ipsilateral stroke was significantly higher in women (risk ratio [RR], 2.38; 95% confidence interval [CI], 1.02 to 5.56; P =.04) and in patients with higher gradients of cardiac and pulmonary risk factors (RR, 2.8; 95% CI, 1.6 to 4.8 per gradient increase; P <.001). The risk was significantly lower in patients who had undergone vein patch angioplasty (RR, 0.29; 95% CI, 0.12 to 0. 71; P =.006) in comparison with synthetic patching. However, 38 of the 55 patients (69%) who underwent synthetic patching also had widespread atherosclerosis for which the saphenous veins already had been harvested for coronary bypass grafting surgery or infrainguinal revascularization., Conclusion: In our experience, the perioperative risk of nonelective CEA primarily is determined by incidental cardiopulmonary disease. Vein patch angioplasty appears to enhance late results, but the late stroke rate associated with synthetic patching also may have been influenced by the extent of vascular disease in our study group.

Purpose: Surgical therapy for splenic artery aneurysms (SAAs) has traditionally consisted of a laparotomy with resection of the aneurysm and possibly a splenectomy. Our early experience with the laparoscopic approach to treat SAAs is reported., Methods: A retrospective review of medical records was conducted on all patients who underwent laparoscopic resection of SAAs at the Cleveland Clinic Foundation from May 1996 to August 1997., Results: Four patients with SAAs, three women and one man, with an average age of 55 years (range, 37 to 63 years), underwent successful laparoscopic SAA repair. The average size of the aneurysm was 3.2 cm (range, 2.5 to 5.0 cm). Three patients underwent an aneurysm resection, whereas one patient underwent simple ligation. Intraoperative ultrasound scanning with Doppler was used in three cases as a means of localizing the aneurysm and identifying all feeding vessels; the complete cessation of flow within the aneurysm in the case in which the feeding vessels were simply ligated was also documented. The average intraoperative time was 150 minutes (range, 100 to 190 minutes). The mean estimated blood loss was 105 mL (range, 20 to 300 mL). There were no intraoperative complications. The average hospital stay was 2.2 days (range, 1 to 4 days)., Conclusion: The laparoscopic approach to splenic artery aneurysm by aneurysmectomy or splenic artery ligation can be safe and effective. The laparoscopic approach affords a short hospital stay and an effective result.

Purpose: The purpose of this study was to determine the safety and efficacy of the elective surgical treatment of symptomatic chronic mesenteric occlusive disease (SCMOD) and to identify the factors that influence the results of this procedure., Methods: From 1977 to 1997, 85 patients (mean age, 62 years) underwent elective surgical treatment of SCMOD. The presenting symptoms were abdominal pain in 78 patients (92%) and weight loss in 74 patients (87%). The surgical procedures included retrograde bypass grafting in 34 patients (40%), antegrade bypass grafting in 24 patients (28%), transaortic endarterectomy in 19 patients (22%), local arterial endarterectomy with patch angioplasty in six patients (7%), thrombectomy alone in one patient (1%), and superior mesenteric artery reimplantation in one patient (1%). Thirty-five patients (41%) underwent concomitant aortic replacement. All the involved mesenteric vessels were revascularized in 21 patients (25%), whereas revascularization was incomplete for the remaining 64 patients (75%). Late information was available for all 85 patients at a mean interval of 4.8 years., Results: There were seven early (<35 days) postoperative deaths (8%). The cumulative 5-year survival rate was 64% (95% confidence interval [CI], 53% to 75%), and the 3-year symptom-free survival rate was 81% (95% CI, 72% to 90%). Serious complications occurred in 28 patients (33%). The results of univariate analysis identified advancing age at operation (P <.001), cardiac disease (P =.03), hypertension (P =.03), and additional occlusive disease (P =.05) as variables associated with mortality. Concomitant aortic replacement (P =.037), renal disease (P =.011), advancing age ( P =.035), and complete revascularization ( P =.032) were associated with postoperative morbidity including mortality. Late recurrent mesenteric occlusive disease was seen in 21 patients (16 symptomatic and five asymptomatic). Nine patients (43%) died, and 8 patients (38%) required subsequent surgical or endovascular procedures to treat their recurrent lesions. The 3-year survival rate from recurrent mesenteric occlusive disease was 76% (95% CI, 66% to 86%)., Conclusion: We conclude that the elective surgical treatment of SCMOD may be performed with reasonable early and late mortality rates and that most of the patients remain free from recurrent symptoms of mesenteric ischemia. Advancing age, cardiac disease, hypertension, and additional occlusive disease significantly influenced the overall mortality rates, and concomitant aortic replacement, renal disease, and complete revascularization were significantly associated with postoperative morbidity rates. Surveillance and appropriate correction of recurrent disease appear to be necessary for optimal long-term results.

Purpose: The initial and long-term results of angioplasty and primary stenting for the treatment of occlusive lesions involving the supra-aortic trunks were studied., Methods: All patients in whom angioplasty and stenting of the supra-aortic trunks was attempted were included in a prospective registry. Results are, therefore, reported on an intent-to-treat basis. The preprocedural and postprocedural clinical records, arteriograms, and noninvasive vascular laboratory examinations of 83 patients (41 men [49.4%] and 42 women [50.6%]; mean age at intervention, 63 years) in whom endovascular repair of the subclavian (66, 75.9%), left common carotid (14, 16.1%), and innominate (7, 8.0%) arteries was attempted were retrospectively reviewed., Results: Initial technical success was achieved in 82 of 87 procedures (94.3%). The inability to cross 4 complete subclavian occlusions and the iatrogenic dissection of 1 common carotid artery lesion accounted for the 5 initial failures. Complications occurred in 17.8% of 73 subclavian and innominate procedures, including access-site bleeding in 6 and distal embolization in 2. Ischemic strokes occurred in 2 of 14 common carotid interventions (14.3%), both of which were performed in conjunction with ipsilateral carotid bifurcation endarterectomy. The 30-day mortality rate was 4.8% for the entire group. By means of life-table analysis, 84% of the subclavian and innominate interventions, including initial failures, remain patent by objective means at 35 months. No patients have required reintervention or surgical conversion for recurrence of symptoms. Of the 11 patients available for follow-up study who underwent common carotid interventions, 10 remain stroke-free at a mean of 14.3 months., Conclusion: Angioplasty and primary stenting of the subclavian and innominate arteries can be performed with relative safety and expectations of satisfactory midterm success. Endovascular repair of common carotid artery lesions can be performed with a high degree of technical success, but should be approached with caution when performed in conjunction with ipsilateral bifurcation endarterectomy.

We report of a case of abnormal cerebral perfusion but normal vascular reserve by single-photon emission computed tomographic imaging in a 65-year-old woman with fibromuscular dysplasia of the internal carotid artery (ICA). The patient had an aneurysm in her left ICA at the level of second cervical vertebra without evidence of stenosis and was excised with primary anastomosis 3 years ago when she presented with months of dizziness. But follow-up angiography showed high-grade long segmental stenosis in her left ICA, characteristic of fibromuscular dysplasia. Because she was asymptomatic with normal vascular reserve, she was treated medically. This report suggests the usefulness of functional imaging in fibromuscular dysplasia. The potential improvement of cerebral perfusion in this rare disease with acetazolamide or dipyridamole is worthy of further clinical investigation.

Purpose: This study was undertaken to determine the safety and efficacy of carotid endarterectomy (CEA) in the octogenarian population at the Cleveland Clinic., Methods: From 1989 to 1995, 182 CEAs were performed among 167 octogenarians (98 men, 69 women) with a mean age of 83 years (median, 83 years; range, 80 to 93 years). One hundred procedures (55%) were performed for severe asymptomatic stenosis, whereas 48 (26%) were performed for hemispheric transient ischemic attacks (TIAs) or amaurosis fugax, 24 (13%) for prior stroke, and 10 (5%) for vertebrobasilar symptoms. Thirteen CEAs (7%) were combined with myocardial revascularization, and another five (3%) represented carotid reoperations. Nine arteriotomies (5%) were closed primarily, whereas the remaining 173 (95%) were repaired using either vein patch angioplasty (141, 77%) or synthetic patches (32, 18%). Two patients were lost to follow-up, but late information was available for 165 patients (180 operations) at a mean interval of 2.7 years (median, 2.4 years; maximum, 7.4 years)., Results: Considering all 182 procedures, there were five early (<30 days) postoperative neurologic events (2.7%), including three strokes (1.6%) and two TIAs (1.1%). An additional 15 neurologic events occurred during the late follow-up period, consisting of 11 strokes (6.1%) and four TIAs (2.2%). The Kaplan-Meier estimated 5-year rate of freedom from stroke was 85% (95% confidence interval [CI], 77% to 93%). There was one early postoperative death (0.6%) of cardiac complications 9 days after CEA. The estimated 5-year survival rate was 45% (95% CI, 33% to 57%), and the 5-year stroke-free survival rate was 42% (95% CI, 30% to 53%). Multivariable analysis yielded age at operation (p = 0.001), abnormal creatinine level (p = 0.025), and chronic obstructive pulmonary disease (p = 0.019) as variables that significantly influenced the survival rate. The presence of chronic obstructive pulmonary disease (p = 0.009) and, surprisingly, a lesser degree of contralateral internal carotid stenosis (p = 0.003) were found to be significantly associated with stroke after CEA. Causes of late death were cardiovascular in 16 patients (30%), unknown in 13 (24%), carcinoma in six (11%), stroke in six (11%), and miscellaneous in 13 (24%)., Conclusions: We conclude that CEA may be safely performed in selected octogenarians with carotid stenosis, and that the majority of these patients live the rest of their lives free from stroke. Therefore, age alone should not exclude otherwise-qualified candidates from consideration for CEA.

Purpose: Since isolated common iliac artery aneurysms are rare and there is no consensus regarding some aspects of their management, we reviewed our recorded experience with common iliac artery aneurysms from 1977 through 1993., Methods: We were able to identify 25 patients having a total of 33 common iliac artery aneurysms on the basis of information maintained by our medical records staff, old surgical logs and a departmental registry that was implemented in 1989. Follow-up data were collected from outpatient charts and by telephone contact. New imaging studies were obtained for 14 patients who either underwent common iliac artery aneurysm repair without aortic replacement (aortic ultrasound scans, n = 7) or had no surgical treatment whatsoever (computerized tomography of the abdomen and pelvis, n = 7)., Results: All 25 patients were men (mean age, 71 years). Eighteen patients (72%) had elective (n = 14) or urgent (n = 4) operations to repair common iliac artery aneurysms with mean diameters of 3.8 cm and 5.8 cm, respectively. There was one postoperative death (5.5%) in conjunction with complementary renal revascularization in a patient with pre-operative renal insufficiency. During a mean follow-up period of 50 months, two (29%) of the seven patients who had not received bifurcation grafts at the time of their common iliac artery aneurysm procedures had developed infrarenal aortic aneurysms. Seven (28%) of the original 25 patients were observed without intervention for common iliac artery aneurysms measuring 2-2.5 cm in diameter. No common iliac artery aneurysm enlargement or new aortic aneurysms have been documented in any of these patients at a mean follow-up interval of 57 months., Conclusions: In our limited experience, the risk for spontaneous rupture appears to be concentrated among common iliac artery aneurysms exceeding 5 cm in diameter, while those that are less than 3 cm in diameter may fail even to enlarge under observation. Therefore, common iliac artery aneurysms measuring > or = 3 cm in size probably warrant surgical treatment, at which time simultaneous aortic replacement also should be a serious consideration.

A few contemporary reports have suggested that the use of epidural anesthesia may favorably influence early graft patency in patients undergoing infrainguinal revascularization. In order to test this hypothesis, we have retrospectively reviewed our experience with 303 primary femoropopliteal-tibial bypass procedures in 294 patients from January 1989 through June 1994. A total of 145 of these operations were done under epidural anesthesia (EA) and 158 under general anesthesia (GA); the demographic profiles for the patients in both of these groups were nearly identical. Thirteen patients (4.2%) died during the perioperative period (EA 3.4%, GA 5.0%; p = 0.48). Early graft thrombosis occurred in 35 patients (12%) during the same hospital admission (EA 14%, GA 9.4%; p = 0.28). There were no significant differences in the graft thrombosis rates for EA and GA with respect to surgical indications (claudication versus limb salvage), graft materials (vein versus synthetic), or the extent of revascularization (popliteal versus crural). Most graft failures appeared to be related to such conventional factors as disadvantaged outflow vessels and/or specific technical complications. Therefore, we conclude that the choice between EA and GA should continue to be made selectively on the basis of traditional anesthetic considerations.

Purpose: Several randomized trials now have established guidelines regarding patient selection for carotid endarterectomy (CEA) that have been widely accepted but have little relevance unless they are considered in the context of perioperative risk. The purpose of this study was to demonstrate the feasibility of early outcome assessment using a computerized database., Methods: Since 1989 demographic information and in-hospital results for all surgical procedures performed by the members of our department have been entered into a prospective registry. For the purpose of this report, we have analyzed the stroke and mortality rates for 2228 consecutive CEAs (2046 patients), including 1924 that were performed as isolated operations and 304 that were combined with simultaneous coronary artery bypass grafting (CABG). This series incidentally contains a total of 153 reoperations for recurrent carotid stenosis., Results: The respective stroke and mortality rates were 0.5% and 1.8% for all isolated CEAs, 4.3% and 5.3% for all CEA-CABG procedures, and 4.6% and 2.0% for carotid reoperations. According to a multivariable statistical model, the composite stroke and mortality rate for isolated CEA was significantly influenced by female gender (p = 0.050), by the urgency of intervention (p = 0.026), and by carotid reoperations (p = 0.024). Gender (p = 0.030) and urgency (p = 0.040) also were associated with differences in the stroke rate alone; furthermore, the incidence of perioperative stroke was higher in conjunction with synthetic patching (odds ratio, 2.6; 95% confidence interval, 1.2 to 5.3) and was marginally higher with primary arteriotomy closure (odds ratio, 2.7; 95% confidence interval, 0.8 to 9.5) compared with vein patch angioplasty (1.3%). The method used to repair the arteriotomy was the only independent factor that qualified for the multivariable composite stroke and mortality models that were applied to the combined CEA-CABG procedures, but too few patients in this cohort had synthetic patches or primary closure to validate the perceived superiority of vein patching., Conclusions: Prospective outcome assessment is essential to reconcile the indications for CEA with its actual results, and it may lead incidentally to important observations concerning patient care.

Purpose: To determine whether gender distinction influence the cardiac risk or survival rates associated with surgical treatment of infrarenal abdominal aortic aneurysms (AAAs)., Methods: From 1983 to 1988, graft replacement of intact AAAs was performed in 490 men (84%) and in 92 women (16%) who had no history of myocardial revascularization before the discovery of their AAAs. Patients of both genders were comparable with respect to mean age (68 years) and the prevalence of coronary artery disease (CAD) by standard clinical criteria (men, 73%; women, 65%). Preoperative coronary angiography was obtained in 471 of the 582 patients (men, 81%; women, 80%) during this particular study period. Preliminary coronary bypass was warranted on the basis of existing indications in 111 (24%) of these 471 patients (men, 25%; women, 18%), including 104 (31%) of the 337 who had clinical indications of CAD (men, 32%; women, 26%) but only 7 (5.2%) of the 134 who did not (men, 6%; women, 4%). Follow-up data were collected during a mean interval of 53 months (men, 54 months; women, 48 months) and were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards models., Results: Twenty-nine perioperative deaths (5.0%) occurred in conjunction with AAA repair (men, 5.1%; women, 4.3%), and 126 early and late deaths have occurred (men, 22%; women, 22%). Survival rates for the series were found to correlate with age (p < 0.001), the serum creatinine level (p < 0.001), and the coronary angiographic classification (p < 0.001). No significant differences were identified between the gender cohorts. The cardiac mortality rate for AAA resection was only 1.8% in the 111 patients who had preliminary coronary bypass, but five additional perioperative deaths (4.5%) related to renal failure or sepsis occurred in this group. However, 5-year survival rates for patients receiving preliminary bypass (men, 82%; women, 75%) were closely comparable with those for patients found to have only mild to moderate CAD by angiography (men, 86%; women, 82%)., Conclusion: We conclude that men and women with AAAs have similar cardiac risks and survival rates associated with surgical treatment. Our results also illustrate that the potential benefit of coronary intervention for severe CAD in patients of either gender must be considered in the context of long-term outcome and the early mortality rate of AAA repair.

The records of 52 consecutive patients who underwent surgical treatment for 57 episodes of hemodialysis graft infection (HGI) from 1977 to 1993 were reviewed to determine the mortality and morbidity associated with this complication and to clarify guidelines for its management. The study group consisted of 35 women and 17 men whose mean age was 57 years at initial graft placement. Thirty-three (58%) HGIs involved straight grafts in the upper arm, 12 (21%) straight forearm grafts, 11 (19%) loop forearm grafts, and 1 (2%) a loop groin fistula. All of these grafts were constructed with polytetrafluoroethylene (PTFE). All 57 cases of HGI showed at least local evidence and 41 (72%) caused systemic symptoms. Thirty-seven (65%) HGIs were associated with positive blood cultures. The predominant infecting organism was Staphylococcus, which was isolated alone or in combination with other organisms from 40 (70%) graft or would sites. Seventy-eight percent (31/40) of the staphylococcal infections involved Staphylococcus aureus. The median time from graft implantation to diagnosis of HGI was 7 months (mean 16 months, range 0 to 77 months) and from diagnosis to surgical treatment, 4 days (mean 6 days, range 0 to 26 days). Initial surgical management consisted of complete excision of all prosthetic material in 43 (75%) cases and partial excision in 14. The 30-day mortality rate following the last operation for the treatment of HGI was 12% (6/52) and was not significantly increased by incomplete excision. Six (86%) of the early deaths were related to sepsis and each of these patients had positive blood cultures.(ABSTRACT TRUNCATED AT 250 WORDS)

Purpose: The purpose was to determine the early and late mortality and morbidity rates associated with infrainguinal arterial prosthetic graft infection (IAPGI) and to identify optimal methods of management., Methods: The study included 53 men and 14 women (mean age, 61 years) in whom a total of 68 IAPGIs developed in the years 1959 to 1993. IAPGI involved 58 femoropopliteal grafts (85%), six femorodistal grafts (9%), and four other grafts or synthetic patches (6%). Graft material was dacron in 36 (53%), polytetrafluoroethylene in 28 (41%), and human umbilical vein in four (6%). Sixteen IAPGIs (24%) involved limbs that had required amputations before IAPGI was diagnosed. Twenty-six (38%) of the 68 grafts were thrombosed, and 14 (88%) of the 16 amputees had occluded grafts., Results: Staphylococcal organisms were isolated from 34 (58%) of the 59 IAPGIs for which culture data were available. The median intervals until IAPGI was diagnosed were 3 months after implantation and 1 month after the last procedure involving the original graft. Initial management consisted of local measures only in 13 (19%), partial removal or in situ graft replacement in 15 (22%), and total graft excision in 40 (59%). Total excision was performed in 15 (94%) of the 16 patients with prior amputations and in only 25 (48%) of the 52 intact limbs. The overall postoperative mortality rate was 18%; seven (58%) of the 12 early deaths were related to sepsis, and all 12 occurred within the group of 51 patients (24%) for whom limb salvage was still being attempted (p = 0.056). IAPGI ultimately led to amputations in 21 (40%) of 52 intact limbs within the first year. Twenty-three (82%) of the 28 IAPGIs managed with incomplete graft removal required subsequent operations for continued sepsis, compared with five (13%) of the 40 treated with complete excision (p < 0.001). The cumulative 5-year survival rate (77%) for 53 patients who survived operation was less than that (89%) for the normal, age-matched U.S. male population., Conclusions: IAPGI is associated with substantial early mortality and amputation rates. Complete excision of infected graft material results in a significant reduction in the incidence of recurrent sepsis.

Purpose: This study was undertaken to determine the mortality and morbidity rates associated with abdominal aortic aneurysm (AAA) repair in octogenarians and to identify factors that may influence survival in this age group., Methods: One hundred fourteen patients (mean age 83 years) were admitted consecutively with 106 infrarenal and eight juxtarenal AAAs from 1984 through 1993. Ninety-four AAAs were asymptomatic, whereas 20 patients with symptoms had 11 intact and nine ruptured AAAs. The mean AAA diameter was 6.7 cm. Repair consisted of aortic bifurcation grafts in 77 patients (67%), tube grafts in 35 (31%), and extraanatomic procedures in 2 (2%). A total of 29 patients (25%) had undergone previous coronary artery bypass (24 patients) or transluminal coronary angioplasty (five patients) either incidentally or as a preliminary procedure before resection of their AAAs., Results: The 30-day mortality rate for the entire series was 14%, but it declined from 23% (11/48) during the first 5 years to 8% (5/66) during the second 5 years of the study period (p = 0.028). Fatal complications occurred in nine (9.6%) of the 94 patients with asymptomatic AAAs and in seven (35%) of the 20 patients who had symptomatic AAAs (p = 0.008). Considering only patients with asymptomatic AAAs, the early mortality rate in the second 5 years (4%) improved significantly (p = 0.038) in comparison to that (17%) for the first 5 years of the study period. The cumulative 5-year survival rate of 48% for 97 available operative survivors was not quite so good as that (59%) for the normal male population of the United States at the age of 80 years (p < 0.0001). Nevertheless, the 5-year survival rate was 80% for 27 operative survivors who received previous myocardial revascularization compared with 38% for 70 others who did not (p = 0.0077). Multiple Cox-regression analysis identified the perioperative homologous blood requirement (p = 0.03) and a history of previous myocardial revascularization (p = 0.03) as significant independent factors influencing late survival., Conclusions: Repair of AAAs in properly selected octogenarians is safe and durable. When otherwise indicated, it should not be withheld on the basis of advanced age alone. Prior treatment of severe coronary artery disease is associated with enhanced late survival, but patient selection probably is an important consideration in this respect.

Purpose: The purpose of this study was to determine the indications and the long-term results for femorofemoral revascularization with autogenous vein grafts (AVG) rather than conventional synthetic materials., Methods: A consecutive series of 13 men and 12 women (mean age 64 years) receiving femorofemoral AVG was collected during a retrospective review of our experience from 1979 to 1992. Sixteen of these 25 patients required revascularization for acute ischemia in the presence of potential groin contamination (group 1), and the remaining nine had frank infections involving previous synthetic grafts (group 2). New grafts were constructed with the greater saphenous vein in 23 patients (92%) and with the cephalic vein in two., Results: One patient in each group (8%) died after operation with patent grafts. Preoperative and postoperative ankle/brachial indexes (ABI) were available for 12 patients in group 1 and for seven patients in group 2. There was significant improvement in the ABI among 11 patients with ischemia in group 1 (mean 0.33 +/- 0.13; p = 0.0001), whereas no change in the ABI occurred in conjunction with the replacement of patent infected grafts among six patients in group 2 (mean 0.04 +/- 0.17; p = NS). One patient from each group sustained a reduction in postoperative ABI for the recipient limb despite a patent AVG. Cumulative 3-year survival and primary patency estimates for all 23 operative survivors were 63% and 75%, respectively. Late results seemed to be comparable in group 1 and group 2, but each contained too few patients for adequate analysis., Conclusions: Despite their infrequent use, AVG seem to represent a reasonable alternative to synthetic bypass for femorofemoral revascularization in patients having either contaminated wounds or established graft infections.

Background: To evaluate the effectiveness of preadmission autologous blood donation (PABD) in reducing the homologous transfusion requirement of abdominal aortic aneurysm resection, the blood product requirements of 145 patients who underwent operation at Cleveland Clinic from September 1987 through May 1991 were reviewed., Methods: A study group of 73 patients underwent aortic grafting for aneurysm after PABD. Intraoperative autotransfusion (IAT) was used routinely. Homologous blood requirements were compared to those of 72 patients at the same center who underwent similar operations using IAT alone. No significant differences were noted in age, gender, cardiovascular risk factors, operation complexity, intraoperative blood loss, or IAT volumes between the two groups. Mean aneurysm size of the study patients (5.4 cm) was slightly less than that of the comparison patients (6.0 cm) (p < or = 0.001). Patients in the study group received a mean of 1.9 units predeposited autologous blood., Results: The mean discharge hematocrit (33.4%) and hemoglobin (11.0 gm/dl) levels of the study group were indistinguishable from those of the comparison group (33.3% and 11.1 gm/dl, respectively). The homologous blood requirement of the study group was significantly less (median, 0; mean, 1.3 units/patient) than that of the comparison group (median, 1.5; mean, 1.9 units/patient) (p = 0.001). Furthermore, 67% (49 of 73 patients) of the study group required no homologous blood although only 36% (26 of 72 patients) of the comparison patients avoided banked blood transfusions (p = 0.0004). No significant differences were found in platelet, fresh frozen plasma, or cryoprecipitate requirements between the study and comparison groups., Conclusions: PABD significantly reduces the homologous blood requirements for elective aortic aneurysm resection and, when used in combination with IAT, eliminates the need for homologous blood in at least two thirds of properly selected patients.

Purpose: The coexistence of horseshoe kidney and aortic aneurysm poses a technical challenge to the vascular surgeon at the time of aneurysm repair. Clinical experience with this problem was reviewed to assess the results of treatment and to develop guidelines for the treatment of patients with horseshoe kidney and aortic aneurysm., Methods: From 1960 through 1991, 19 patients with associated horseshoe kidney (HSK) required repair of abdominal aortic aneurysm at the Cleveland Clinic. Seventeen men and two women, with a mean age of 67 years, underwent 16 elective and three urgent operations. The HSK was found before operation in 16 patients (84%), whereas the remaining three were discovered at operation. Computed tomography and intravenous pyelography were the most reliable means of preoperative diagnosis, whereas ultrasonography and aortography were less dependable. Mean size of abdominal aortic aneurysm was 6.1 cm. The mean preoperative creatinine level was 1.5 mg/dl. The surgical approach was transperitoneal in 16 patients and retroperitoneal in three. Division of the renal isthmus was avoided in all patients., Results: Renal artery anomalies were encountered in 14 patients (74%). Renal arterial continuity was established by a variety of techniques, including branch grafts or reimplantation into the aortic graft. Abnormal preoperative renal function was associated with a significantly increased risk for early postoperative hemodialysis (p = 0.02). There were three postoperative deaths, and the mortality rate for patients who required dialysis (67%) was significantly higher (p = 0.05) than that for patients who did not (6.3%). There were six late deaths at a mean follow-up interval of 57 months., Conclusions: The most important aspect of HSK, therefore, is the appropriate surgical management of frequent renal artery anomalies. We currently believe this is best achieved with retroperitoneal exposure.

Purpose: Between 1977 and 1991, 405 patients with atherosclerotic occlusive disease of the superficial femoral artery underwent clinical as well as noninvasive laboratory evaluation and were recommended for nonoperative treatment., Methods: Limbs with uncorrected aortoiliac occlusive disease, aneurysmal degeneration, or previous femoropopliteal bypass were excluded, leaving 568 involved extremities. Complete follow-up, which forms the basis for this report, was available in 377 patients (93%) with 520 limbs (93%). Patients were monitored for a minimum period of 2 years (range, 24 to 164 months; median, 86 months). During the surveillance period 45 limbs (8.6%) in 42 patients (11.1%) required arterial intervention. This entailed operation in 39 cases and endovascular treatment in six cases. With use of life-table analysis, the risk for intervention was found to be 11% at 5 years and 14% at 10 years. A total of 14 limbs (2.7%) in 14 patients (3.7%) ultimately required major limb amputation, either after failed bypass (8 patients) or as a primary procedure (6 patients)., Results: Analysis of risk factors revealed that female sex (p = 0.04), chronic renal failure (p = 0.0001), diabetes mellitus (p = 0.0011), history of contralateral femoropopliteal bypass (p = 0.0005), level of disease (p = 0.003), and entry ankle/brachial index less than 0.50 (p = 0.004) were associated with an increased risk over time for intervention. Other factors, including age, current or prior smoking history, hypertension, and the presence of coronary artery disease or cerebrovascular disease failed to reach statistical significance., Conclusions: These data support the continued conservative approach to surgery for patients with superficial femoral artery occlusive disease without limb-threatening symptoms. Patients with multilevel disease, lower ankle/brachial index, a history of contralateral femoropopliteal bypass, chronic kidney failure, or diabetes mellitus are at increased risk and should be monitored more closely.

Between May 1966 and June 1991, 129 patients underwent surgical repair of thoracoabdominal aneurysms, with an overall 30-day mortality rate of 35%. In 75 operations (58%) performed electively, 11 deaths (15%) occurred, and in 54 cases (42%) of either symptomatic or ruptured aneurysms 34 deaths (63%; p less than 0.001) occurred. No one survived among six patients with preoperative hypotension (less than 90 mm Hg) or cardiac arrest. In 16 patients (12%) the etiology of aneurysms was a result of chronic aortic dissection, and the mortality rate in this subgroup was 44%. In the remaining 113 patients (88%) where the etiology was atherosclerosis, 38 deaths occurred (34%; p = 0.433). Spinal cord ischemia occurred in 25 cases (21%) among 116 patients who survived operation. Partial ischemia occurred in six cases (25%), and complete paraplegia occurred in the remainder. Complete and partial paraplegia occurred in 16 of 42 cases (38%) when all of the thoracic aorta was replaced (Crawford groups I, II) and in 9 of 74 cases (12%) when only the abdominal or lower thoracic aorta was replaced (Crawford groups III, IV; p = 0.016). Other complications included myocardial infarction (14 cases, 11%), respiratory failure (46 cases, 36%), and renal failure (33 cases, 27%). The major prospect for improved early survival of patients with thoracoabdominal aneurysms seems to be early detection and elective repair before the occurrence of symptoms.

From January 1983 to September 1990, 2731 carotid endarterectomies were performed at The Cleveland Clinic. Patch angioplasty with autogenous saphenous vein was used for arteriotomy closure during 1691 (62%) of these procedures and was associated with eight postoperative ruptures (0.5%) of the central portion of the patch in seven patients. This complication occurred in three men and in four women (mean age, 69 years), all of whom were hypertensive and all but one were smokers. Two patients (29%) had diabetes. In each case of patch rupture the vein had been harvested from the leg distal to the knee. Although the harvest site could not be determined retrospectively for every patient in this series, no patch ruptures were encountered among 370 procedures for which it could be documented that the saphenous veins had been obtained from the groin. All ruptures occurred within 5 days of the primary operations (including four during the first 24 hours) and were urgently corrected by primary closure of the original arteriotomy in two cases and by replacement of the ruptured patch in the remaining six. Two (29%) of the seven patients either died or sustained a permanent neurologic deficit. Central rupture of a saphenous vein patch is a rare but devastating complication after carotid endarterectomy. Since vein harvested from the lower leg or ankle may be marginally more likely to rupture than proximal vein from the thigh or groin, it should not be used indiscriminately for carotid patch angioplasty.

From 1980 to 1989 infrainguinal revascularization was performed with cephalic vein grafts in a consecutive series of 34 patients (35 limbs) whose saphenous veins were either inadequate or already had been harvested for previous coronary (N = 16, 47%) or ipsilateral lower extremity bypass (N = 19, 56%). Surgical indications included ischemic rest pain or focal tissue necrosis in 25 limbs (71%), disabling claudication in six (17%), and popliteal aneurysms or prosthetic femoropopliteal graft infections each in two (6%). Preliminary arteriovenous fistulas were constructed in the arms of 23 patients (68%) to enhance the diameter of their cephalic veins, and 24 (69%) of the 35 infrainguinal procedures in this series were performed with use of cephalic vein alone. The distal popliteal artery was used for the outflow anastomosis in 10 limbs (29%), a tibial vessel was used in 12 (34%), and the peroneal artery was used in 13 (37%). Fourteen graft occlusions (40%) and six amputations (17%) have occurred during follow-up intervals of 1 to 107 months (mean, 28 months; median, 27 months). At 3 years the cumulative primary patency rate is 40%, the secondary patency rate is 46%, and the limb salvage rate is 82%. Despite their relative inconvenience, cephalic vein grafts appear to be preferable to prosthetic materials for infrainguinal revascularization below the knee.

The surgical management of carotid body tumors requires identification and preservation of neural and vascular structures without compromising resection of the neoplasm. Fifteen patients were examined and treated for carotid body tumors at the Cleveland (Ohio) Clinic Foundation from 1979 through 1987. The benchmark of diagnosis is bilateral carotid angiography. When neural structures are free of tumor, meticulous dissection facilitates their preservation. Large tumor size increases risk for arterial resection necessitating reconstruction. The use of a vascular shunt minimizes the risk of cerebral ischemia. Postoperative intravenous digital subtraction angiography allows for evaluation of arterial repair. A retrospective review of 15 carotid body tumor resections performed in 14 patients revealed no evidence of tumor recurrence, no mortality associated with surgical intervention, no postoperative cerebrovascular accident, and limited morbidity associated with unavoidable sacrifice of neural elements.

A consecutive series of 532 patients (1.5%) required local thrombectomy and arterial repair after 34,291 transbrachial cardiac catheterizations performed at the Cleveland Clinic from 1980 to 1988. A total of 514 patients (97%) were discharged from the hospital with normal radial pulses and/or normal ulnar pulses after a single surgical procedure. Fourteen others (3%) each required one additional procedure to regain a distal pulse, and four patients either underwent two reoperations, received thrombolytic therapy, and/or remained pulseless. Surgical delay of more than 1 day after catheterization was associated with a higher incidence of recurrent thrombosis (12% vs 2%, p = 0.025). In comparison to our previous experience with iatrogenic brachial injuries, the liberal use of segmental arterial resection and overnight heparin anticoagulation seem especially to reduce the risk for early failure in all patients, but improvement was particularly marked in women (25% vs 6%, p = 0.0004).

From 1979 to 1983, 1726 carotid endarterectomies were performed at the Cleveland Clinic. During this period, 39 men (mean age, 60 years) and 22 women (mean age, 63 years) required 65 reoperations (3.8%) for correction of recurrent carotid stenosis occurring 3 to 194 months (mean, 42 months) after previous endarterectomy at this center (N = 43) or elsewhere (N = 22). Remedial procedures were necessary because of restenosis demonstrated by routine noninvasive testing in 32 asymptomatic lesions and because of neurologic symptoms in 33 others. The mean recurrence interval was 57 postoperative months for atherosclerosis (N = 37) in comparison to 21 months (p = 0.0007) for myointimal hyperplasia (N = 28), and was 48 months for men in comparison to 31 months for women (p = NS). Hypercholesterolemia appeared to be associated with late atherosclerotic recurrence (p = 0.05), but was not a feature of myointimal hyperplasia. Patch angioplasty (N = 59) or graft replacement (N = 3) was employed during 62 of the 65 reoperations, with a total of two operative deaths (3.1%), one nonfatal stroke (1.5%), and six transient cranial nerve injuries (9.2%). Three unrelated late deaths have occurred within a mean follow-up period of 23 months, but only three patients have experienced subsequent neurologic symptoms.

In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography was performed in 1000 patients (mean age, 64 years) under consideration for elective peripheral vascular reconstruction since 1978. Those found to have severe, surgically correctable coronary artery disease (CAD) were advised to undergo myocardial revascularization (CABG), usually preceding other vascular procedures. The primary vascular diagnosis was abdominal aortic aneurysm (AAA) in 263 patients (mean age, 67 years), cerebrovascular disease (CVD) in 295 (mean age, 64 years), and lower extremity ischemia (ASO) in 381 (mean age, 61 years). Severe correctable CAD was identified in 25% of the entire series (AAA, 31%; CVD, 26%; and ASO, 21%). Surgical CAD was documented in 34% of patients suspected to have CAD by clinical criteria (AAA, 44%; CVD, 33%; and ASO, 30%) and in 14% of those without previous indications of CAD (AAA, 18%; CVD, 17%; and ASO, 8%). Cardiac procedures (216 CABG) were performed in 226 patients (AAA, 30%; CVD, 22%; and ASO, 19%), with 12 (5.3%) postoperative deaths. A total of 796 patients underwent 1066 peripheral vascular operations with an early mortality of 2.0% (AAA, 3.4%; ASO, 1.9%; and CVD, 0.3%), but only one death (0.8%) occurred in the group of 130 patients having preliminary CABG. The overall operative mortality for 1292 cardiac and peripheral vascular procedures was 2.6%.

Eleven patients undergoing operation on the descending or thoracoabdominal aorta were administered papaverine intrathecally in an attempt to protect the spinal cord from ischemic damage. Concurrently, 19 patients, also undergoing operation on the thoracic or thoracoabdominal aorta, were operated on with a variety of conventional techniques, including distal aortic perfusion, but were not given intrathecal papaverine. No signs of early neurologic injury developed in any of the patients in the intrathecal papaverine group, although delayed paraparesis developed in one of the patients (9%; 70% confidence limits = 1% to 28%). On the other hand, eight of 19 patients undergoing operation with conventional techniques had either lower extremity paraparesis or paraplegia postoperatively (42%; 70% confidence limits = 29% to 57%; p = 0.058). Intrathecal papaverine appeared to provide spinal cord protection during thoracic aortic operations, particularly during prolonged periods of aortic cross-clamping. Papaverine was not associated with increased risk and may be superior to other conventionally used modalities. We conclude that continued evaluation of this technique is justified.

Twenty-two patients were selected from a group of 33 patients who underwent recombinant human tissue-type plasminogen activator (rt-PA) thrombolysis for thrombosed infrainguinal bypass grafts of the lower extremity and were compared with 38 matched patients who had undergone surgical thrombectomy during the same period. The proportion of persons with diabetes mellitus, smokers, and types of bypass grafts was similar in both groups. More patients in the rt-PA-treated group had hypertension (p = 0.01). To evaluate the different lengths of follow-up, Kaplan-Meier survival analysis was used with a log-rank test to compare the proportion of persons with patent grafts in the two treatment groups. At 30 days, 86% of the rt-PA-treated grafts were still patent compared with 42% of the surgically treated grafts (p = 0.001). When risk factors on the Kaplan-Meier curves were compared, there was no statistical difference with regard to graft patency among the groups. According to simultaneous Cox regression analysis, no risk factor was significantly associated with graft patency. When amputation was evaluated between treatment groups simultaneously with other risk factors in a logistic regression analysis, smoking and age of the graft were marginally significant (p = 0.07), whereas all other factors were clearly not significant. In 91% of the rt-PA-treated patients, a secondary surgical procedure was required to maintain patency of the graft segment. Eighty-nine percent of the surgically treated patients required similar graft revisions. Two patients in the surgical group and one patient in the rt-PA-treated group had major complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriovenous fistulae of the mesenteric circulation are rare, only 30 cases having been reported in the English literature. These lesions may follow operations on the abdominal viscera or abdominal injuries, either blunt or penetrating. We report a case of an iatrogenic mesenteric arteriovenous fistula diagnosed 20 years after a small bowel resection for an ileocecal intussusception. A review of the English literature is presented and the diagnosis, treatment, and pathophysiology of mesenteric arteriovenous fistulas is discussed, with special emphasis on the possible sequelae of a hyperkinetic portal blood flow.

The presence of periprosthetic gas on computerized axial tomography (CT) of the abdomen following abdominal aortic reconstruction has been proposed to be a reliable indicator of prosthetic graft infection, a complication that requires intervention entailing significant mortality and morbidity. To evaluate the reliability of this finding in the early postoperative period, prosthetic grafts in 26 patients undergoing elective aneurysm repair were evaluated with postoperative CT examinations. Serial scans were obtained at mean intervals of 3, 7, and 52 days postoperatively. The presence or absence of periprosthetic air on CT scan was noted, and the results were correlated with aneurysm size as determined by preoperative ultrasound examination of the abdominal aorta or by measurements made during operation. Mean aneurysm size was 6.1 cm (range 4.5 to 10.6 cm). Periprosthetic air was demonstrated in 17 (65%) of the 26 patients studied within 1 week postoperatively. Patients with aneurysms larger than 6.0 cm were more likely to demonstrate periprosthetic air then those with smaller aneurysms (chi 2 = 5.024, p = 0.025). All patients found to have periprosthetic air had spontaneous resolution by late CT scanning obtained a mean of 52 days postoperatively (range 21 to 85 days). One patient died in the early postoperative period and two did not return for late scans. Only one patient demonstrated periprosthetic air as late as the thirty-second postoperative day, and this air had resolved by the seventieth postoperative day.(ABSTRACT TRUNCATED AT 250 WORDS)

Thirty-three patients with thrombosed peripheral arteries and bypass grafts, as confirmed by angiography, were treated with recombinant human tissue-type plasminogen activator (rt-PA). Twenty-six patients were treated with a dose of 0.1 mg/kg/hr and seven patients with 0.05 mg/kg/hr. Thrombus lysis and clinical improvement occurred in 22 of 26 (85%) patients in the 0.1 mg/kg/hr group. In seven of seven (100%) patients in the 0.05 mg/kg/hr group angiographic as well as clinical improvement were observed. Fifteen of the 33 patients required anticoagulation to maintain patency. Sixteen required secondary procedures to maintain patency. One (3%) patient required a blood transfusion for a hematoma at the catheter entry site. Three other patients developed small hematomas that were controlled without transfusion or intervention. Sixty-one percent of patients treated with the 0.01 mg/kg/hr dose and 86% of patients treated with the 0.05 mg/kg/hr dose maintained fibrinogen levels greater than 50% of their initial values. Infusion durations ranged from 1 to 6 hr (mean 3.9 hr). rt-PA appears to be a potent and selective thrombolytic agent that rapidly and safely lyses thrombi in peripheral arteries and occluded bypass grafts.

Arteriographic criteria were used to classify 376 consecutive patients who underwent aortobifemoral bypass for aortoiliac occlusive arterial disease between 1967 and 1977. Group A (126 patients, 34%) had isolated aortoiliofemoral disease, group B (156 patients, 41%) had associated femoropopliteal disease, and group C (94 patients, 25%) had associated femoropopliteal and tibioperoneal disease. Ischemic rest pain or tissue necrosis was the indication for operation in 13% of patients in group A, 30% of those in group B (P < 0.01), and 45% of those in group C (P < 0.001). The overall operative mortality rate was 5.6%, and differences in operative mortality among the three groups had no statistical significance. Fatal postoperative myocardial infarctions occurred in 4.5% of the entire series and accounted for 17 (81%) of 21 postoperative deaths. Late follow-up information for 3 to 13 postoperative years (mean, 6.3 years) was available for 337 (95%) of 355 operative survivors. Subsequent femoropopliteal or femorotibial bypass was necessary for 8% of patients in group A, 13% of those in group B, and 19% of those in group C (P < 0.05), but the presence of distal occlusive disease was not associated with meaningful differences in cumulative aortofemoral limb patency or major amputation. The late mortality rate was 28% for group A, 33% for group B, and 41% for group C. Myocardial infarctions were responsible for 46% of all late deaths and occurred in 11% of patients in group A, 15% of those in group B, and 20% of those in group C. The mortality rate (P < 0.01) and the incidence of fatal myocardial infarction (P < 0.02) within five postoperative years were statistically significant in group C.

There is a common belief that administration of anticoagulants to patients with brain tumors is contraindicated. Between 1982 and 1986, 50 patients with deep venous thrombosis and pulmonary emboli and brain tumors were examined and treated. Twenty-four patients received an inferior vena cava Greenfield filter and 25 patients were treated with anticoagulants. One patient was terminal and received no therapy. Patients in each group were similar with regard to age, sex, primary tumor, computed tomographic findings, and ultimate outcome. At the time of diagnosis, all patients had residual tumor and most had significant cerebral edema and midline shift. There were no complications in the group receiving Greenfield filters. One patient had a pulmonary embolus after the filter was placed and later required anticoagulant therapy. In the group receiving anticoagulants, one patient had focal intraventricular bleeding observed incidentally on computed tomographic scan one month after beginning anticoagulant therapy and was totally asymptomatic. One patient had gastrointestinal tract bleeding five days after beginning anticoagulant therapy with heparin sodium, and the therapy was therefore discontinued. No other patient had significant bleeding. In view of these findings, a reevaluation of anticoagulant therapy in patients with central nervous system tumors is warranted.

In a study of 53 cases, aneurysm size was measured with the use of preoperative physical examination, lateral abdominal roentgenography, and B-mode aortic ultrasonography for comparison with direct intraoperative measurement during aneurysmectomy. Mean aneurysm diameter on the basis of physical examination overestimated aortic size by 1 cm; physical examination measurement was within 0.5 cm of true aortic size in 38% of patients and within 1 cm in 58% of patients. The lateral roentgenogram also overestimated mean aortic diameter by 1 cm and was within 0.5 cm of true aortic size in 44% of patients and within 1 cm in 72% of patients. Measurement using B-mode aortic ultrasonography closely approximated intraoperative aneurysm measurement. Measurement was identical in 34% of patients and was within 0.5 cm and 1 cm in 75% and 92% of patients, respectively.

Simultaneous carotid disease was documented in 275 (2.8%) of 9714 patients scheduled for coronary artery bypass (CAB), including 80 (29%) who had had previous neurologic events and 195 with severe (greater than or equal to 70% diameter), asymptomatic carotid stenosis. Preliminary carotid endarterectomy (CE) was feasible before CAB in only 24 patients with stable cardiac disease (group I). Another 129 patients with unstable disease (group II) had unilateral, asymptomatic carotid lesions and were prospectively randomized to receive either combined operations (IIA; n = 71) or CAB followed by delayed CE (IIB; n = 58). The remaining 122 patients (group III) had symptomatic or bilateral carotid stenosis and were managed on a selective basis without randomization. The operative mortality rate ranged from 4.2% to 5.2%, and the early stroke rates were 4.2% in group I, 7.8% in group II, and 11% in group III. Postoperative strokes occurred after CAB in nine (4.7%) of the 193 patients protected by preliminary or simultaneous CE, compared with six (7.4%) of the 81 who received only delayed CE. Nevertheless, the composite stroke risk for "reverse-staged" procedures in group IIB (14%) exceeded that for combined operations (2.8%) in group IIA (p = 0.045). The stroke rate was 11% (7/61) when delayed CE was performed within 2 weeks after CAB compared with 2.2% (1/46) with longer staging intervals.

We reviewed the results, systemic effects, and complications associated with the selective infusion of low-dose streptokinase in 151 patients. Successful thrombus lysis was achieved in 78% of atherosclerotic thrombotic occlusions less than 30 days old, in 81% of post-procedural occlusions less than 14 days old, and in 87% of patients with thrombosed arteriovenous fistulas no more than 4 days old. During the first 12 hours of treatment 81% to 84% of patients had greater than 50% decrease in plasma fibrinogen levels and 100% showed the same decline after 24 hours of treatment. The thrombin time was prolonged to at least 1 1/2 times the control thrombin time in 33% to 42% of patients measured at 4 hours of therapy and in 93% to 97% of patients measured at 24 hours of treatment. Fifteen patients (9.9%) had major complications. Eleven of these had hemorrhagic complications, two had significant distal emboli, one had a thrombosed brachial artery, and one had a false aneurysm at the catheter entry site. We have found that selective low-dose streptokinase is effective in the treatment of acute and chronic thrombotic occlusions and is a useful adjuvant to vascular reconstruction or percutaneous transluminal angioplasty. Although the local infusion dose is substantially lower than the usual systemic dose, a systemic lytic effect was seen in all patients. Hemorrhagic complications occurred despite customary precautions.

From 1973 through 1984, graft replacement of infrarenal aortic aneurysms (N = 56) or occlusive disease (N = 33) was performed in conjunction with simultaneous renal revascularization in 89 patients. Isolated renal artery stenosis was corrected by unilateral reconstruction in 56 patients (63%), but the remaining 33 (37%) had diffuse involvement that required either bilateral renal artery grafts or unilateral revascularization of solitary kidneys. The incidence of hypertension (greater than 180/90 mm Hg) refractory to preoperative medical therapy (88%), severe coronary disease documented by angiography (40%), and postoperative azotemia (33%) or oliguric renal failure (15%) was significantly higher among patients with bilateral renal artery disease (p less than 0.05). In addition, this group had twice the early mortality rate (15%) of patients having unilateral renal artery lesions (7.1%). During a mean follow-up interval of 37 months, medical control of hypertension was enhanced in 46 of the 80 operative survivors (58%), and renal function improved or remained stable in 63 survivors (79%). Five-year actuarial survival presently is 65% for the entire series, with a cumulative mortality rate of 38% among patients who underwent aneurysm resection (mean age 64 years) in comparison to 15% (p = 0.03) for those patients with aortoiliac occlusive disease (mean age 60 years).

In an attempt to reduce early and late mortality caused by myocardial infarction in patients with aortic aneurysms, coronary arteriography and, when indicated, myocardial revascularization were performed prior to elective aortic reconstruction in 302 patients with infrarenal (289) or thoracoabdominal (13) aortic aneurysms. Severe correctable coronary artery disease (CAD) was identified in 31% of the entire series, whereas severe inoperable CAD was seen in another 5%. Severe, correctable CAD was documented in 42% of patients suspected to have CAD by standard clinical criteria and in 19% of those in whom CAD was not suspected. The overall mortality for 89 cardiac and 227 infrarenal aortic surgical procedures was 4,4%. Fatal complications after infrarenal aneurysm resection occurred in only one (1.6%) of 61 patients who had had preliminary myocardial revascularization.

Developmental abnormalities consisting of focal absence of the arterial media have been implicated in the formation of the arterial aneurysms commonly observed in the intracranial cerebrovascular system. However, this observation has rarely been associated with visceral or peripheral arterial aneurysm formation. This article describes the experience with two patients having multiple peripheral and visceral arterial aneurysms with histologic findings previously observed only in intracranial, saccular berry aneurysms and in one patient with an isolated common carotid artery aneurysm. The two patients described herein had no clinical or angiographic evidence of cerebrovascular aneurysm formation. Light and electron microscopic histologic studies revealed complete focal absence of the arterial media in the region of aneurysm formation. No clinical or laboratory evidence of associated collagen-vascular disease was demonstrated. The patients were successfully managed with segmental resection and grafting of symptomatic, expanding, or large aneurysms. The necessity for an aggressive search for associated aneurysms as well as the need for long-term follow-up when histologic evidence of medial agenesis is demonstrated in association with arterial aneurysm formation are emphasized.

Cardiac catheterization was performed in a prospective series of 1000 patients under consideration for elective peripheral vascular reconstruction at the Cleveland Clinic from 1978-1982. Of these, 246 patients (mean age: 68 years) presented primarily because of infrarenal abdominal aortic aneurysms (AAA) and are eligible for subsequent evaluation 3-7 years (mean: 4.6 years) after entrance into the study. Severe, surgically correctable coronary artery disease (CAD) was documented in 78 patients (32%) in the AAA group, and 70 patients (28%) received myocardial revascularization with four fatal complications (5.7%). A total of 56 patients in this subset had staged aneurysm resection, usually during the same hospital admission after coronary bypass, with a single death (1.8%) caused by cerebral infarction. The overall operative mortality rate for 126 coronary and AAA procedures was 4%. A total of 59 additional patients (25%) died during the late follow-up interval, including 14 patients (5.9%) with cardiac events and eight patients (3.4%) with ruptured aneurysms. The cumulative 5-year survival rate (75%) and cardiac mortality rate (5%) after coronary bypass reflected traditional parameters (preoperative ventricular function, completeness of revascularization) and are nearly identical to the results calculated for patients having normal coronary arteries or only mild to moderate CAD. In comparison, the cumulative survival and cardiac mortality rates in a small subset of patients with severe, uncorrected coronary involvement currently are 29% (p = 0.0001) and 34%, respectively. These data support the conclusion that selected patients who require elective resection of AAA also warrant myocardial revascularization to enhance perioperative risk and late survival.

Thirteen of 1,250 patients required a second operation for recurrent stenosis following carotid endarterectomy performed at the Cleveland Clinic between 1958 and 1978. Two other patients underwent reoperation because of recurrent stenosis following primary operations at other institutions. Thirteen of the 15 patients experienced neurologic symptoms caused by recurent stenosis, while two patients remained asymptomatic. Atherosclerosis was responsible for recurrent stenosis in 12 patients and appeared to be related to hypercholesterolemia. Three of the patients had myointimal fibroplasia. Eleven of the 16 reoperations for recurrent stenosis of the carotid artery consisted of carotid endarterectomy with vein patch angioplasty. Three patients had carotid endarterectomy with closure of the primary arteriotomy. One patient with occlusion of the internal carotid artery underwent endarterectomy of the external carotid artery because of amaurosis fugax, and a saphenous vein interposition graft was used to replace a previous Dacron graft in one patient with anastomotic stenosis. One patient had a stroke during reoperation manifest as multiple retinal emboli. Fourteen patients have remained asymptomatic from one to 70 months following reoperation. One patient with occlusion of the contralateral internal carotid artery has experienced persistent vertebrobasilar symptoms.