RESUMEN
PURPOSE: Mesenteric revascularization for chronic mesenteric ischemia (CMI) traditionally involves antegrade or retrograde bypass graft originating from the supraceliac or infrarenal aorta. The distal thoracic aorta (DTA) may provide a better inflow source than the abdominal aorta. The purpose of this study was to evaluate the results with the DTA used as inflow for the surgical treatment of CMI. METHODS: All patients undergoing mesenteric revascularization for CMI with grafts originating from the DTA were identified from 1990 to 1999. A ninth interspace thoracoretroperitoneal incision was used for exposure, and distal aortic flow was maintained by use of a partial occlusion clamp. RESULTS: Eighteen consecutive patients with CMI underwent mesenteric bypass grafting with the DTA used as inflow. All patients were admitted with chronic abdominal pain or weight loss, with two (12%) requiring urgent revascularization because of acute exacerbation of chronic symptoms. Fourteen (78%) patients had both celiac and superior mesenteric artery bypass grafts placed, and three (17%) patients had superior mesenteric artery grafts alone. There was one (6%) perioperative death and three (17%) major complications. There was no kidney failure, mesenteric infarction, or spinal cord ischemia. The life-table survival rate was 89%, 89%, and 76% at 1, 3, and 5 years, respectively. All 18 patients remained symptom free and required no additional procedures to assist patency. There was no evidence of graft stenosis or occlusion (100% patency) for those grafts evaluated objectively during the mean follow-up of 34.8 months (range, 1-97 months). CONCLUSIONS: Antegrade mesenteric revascularization with the DTA used as inflow is associated with low morbidity and mortality rates. Furthermore, it provides excellent midterm patency and survival results and should be considered as a primary approach for reconstruction of patients with CMI.
Asunto(s)
Aorta Torácica/cirugía , Oclusión Vascular Mesentérica/cirugía , Adulto , Anciano , Implantación de Prótesis Vascular , Arteria Celíaca/trasplante , Enfermedad Crónica , Femenino , Humanos , Isquemia/cirugía , Tablas de Vida , Masculino , Arteria Mesentérica Superior/trasplante , Oclusión Vascular Mesentérica/mortalidad , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Tasa de Supervivencia , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
Vascular injury of the popliteal artery or its branches after knee arthroscopy is a rare but potentially devastating complication. We report two cases of sural artery branch pseudoaneurysms resulting from knee arthroscopy. Both patients were successfully treated with transcatheter embolization of the pseudoaneurysms. the diagnosis and treatment options of this unusual injury are discussed.
Asunto(s)
Aneurisma Falso/diagnóstico por imagen , Artroscopía , Rodilla/irrigación sanguínea , Complicaciones Posoperatorias/diagnóstico por imagen , Adulto , Aneurisma Falso/terapia , Angiografía , Arterias/lesiones , Embolización Terapéutica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/terapiaRESUMEN
PURPOSE: The incidence of deep venous thrombosis (DVT) in patients undergoing infrainguinal bypass graft procedures has not been well documented, and the need for routine prophylaxis remains controversial. The purpose of this study was to prospectively evaluate the risk of postoperative DVT complicating infrainguinal revascularization. METHODS: Seventy-four patients undergoing infrainguinal bypass graft procedures during a 12-month period were prospectively screened for DVT. Bilateral lower extremity venous duplex scan imaging was performed preoperatively and within 1 week and 6 weeks, postoperatively. Routine DVT prophylaxis was not used, with anticoagulation reserved for specific indications. RESULTS: Of the 74 patients screened, three patients (4.1%) had DVT identified on preoperative venous duplex scan imaging and were excluded from the study. Of the remaining 71 patients enrolled, only two patients (2.8%) had postoperative DVT. Postoperative DVT was ipsilateral to the bypass graft extremity in both patients, with involvement of the peroneal vein in one patient and the femoral vein in the other. Although routine prophylaxis was not used, 18 of these patients (25%) were anticoagulated for other indications, with DVT occurring in one patient (5.6%). Of the remaining 53 patients who did not receive postoperative anticoagulation, only one patient (1.8%) had DVT. CONCLUSIONS: According to this prospective study, the risk of postoperative DVT in patients undergoing infrainguinal revascularization is low. Routine prophylaxis is not recommended, with postoperative anticoagulation reserved for specific indications.
Asunto(s)
Isquemia/cirugía , Pierna/irrigación sanguínea , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Vasculares , Trombosis de la Vena/etiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Isquemia/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ultrasonografía Doppler DúplexRESUMEN
PURPOSE: Bypass grafts that originate from the descending thoracic aorta to the iliac or femoral arteries are well described but are not commonly used as primary procedures, and the long-term results remain unknown. A 15-year experience with 50 descending thoracic aorta to iliofemoral artery bypass grafts for aortoiliac occlusive disease is the basis of this report. METHODS: From January 1983 to December 1997, patients who underwent bypass grafting procedures from the descending thoracic aorta to the iliac or femoral arteries were identified. Surgical indications, morbidity and mortality rates, primary and secondary patency rates, limb salvage rates, and survival rates were determined. RESULTS: Fifty descending thoracic aorta to iliofemoral artery bypass grafting procedures were performed 24 (48%) for severe claudication, 22 (44%) for rest pain, and 4 (8%) for ischemic ulceration. A primary procedure was performed in 31 patients (62%) for complete occlusion (21 patients) and severe atherosclerotic disease (10 patients) of the infrarenal aorta. The indications for 19 secondary revascularizations (38%) were prior aortic or extra-anatomic graft failure in 17 cases and aortic graft infection in 2 cases. The follow-up periods ranged from 1 to 150 months (mean, 39 months). The cumulative life-table 5-year primary patency, secondary patency, limb salvage, and survival rates were 79%, 84%, 93%, and 67%, respectively. An improved patency trend was observed for patients who underwent operation for severe claudication as compared with limb-threatening ischemia (92% and 69%; P =.07). However, there was no difference between primary and secondary operations in primary patency rates (81% and 79%; P = NS) or survival rates (72% and 62%; P = NS). CONCLUSION: Descending thoracic aorta to iliofemoral artery bypass grafting has excellent overall long-term results. These results support its more liberal use for primary revascularization, especially for patients with severe atherosclerotic disease or complete occlusion of the infrarenal aorta.
Asunto(s)
Aorta Torácica/cirugía , Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Arteria Ilíaca/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/mortalidad , Arteriosclerosis/cirugía , Femenino , Humanos , Tablas de Vida , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/métodos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
PURPOSE: The efficacy of color flow duplex imaging (CFDI) in detecting proximal upper extremity venous outflow obstruction in hemodialysis patients was compared with that of traditional contrast venography. METHODS: From 1993 through 1997, all hemodialysis patients who were evaluated for upper extremity venous outflow obstruction of the axillary, subclavian, or brachiocephalic veins with both CFDI and venography were identified. Medical history, hemodialysis access procedures, and indications for imaging were reviewed. The diagnostic accuracy of CFDI was compared with that of venography for proximal venous outflow obstruction, including focal stricture, partial obstruction, or complete occlusion. RESULTS: Sixty upper extremities in 42 hemodialysis patients were imaged with both CFDI and venography. Previous ipsilateral intravenous dialysis catheters had been present in 33 (55%) of the extremities imaged; current catheters were present in 16 (27%) of the extremities imaged; and 28 (67%) of the extremities imaged had a current ipsilateral arteriovenous (AV) shunt. Five (8%) of the 60 duplex scans were nondiagnostic because of artifact from intravenous dialysis catheters (3) or incomplete visualization of the subclavian or brachiocephalic veins (2) and were excluded from further analysis. In the remaining 55 duplex scans, proximal venous outflow obstruction was found in 18 (33%), compared with 21 (38%) identified by means of venography (P = not significant [NS]). Overall sensitivity, specificity, positive predictive value, and negative predictive value for CFDI were 81%, 97%, 94%, and 89%, respectively. CONCLUSION: CFDI is a reliable means of detecting proximal upper extremity venous outflow obstruction and should replace contrast venography as the initial imaging study in hemodialysis patients.
Asunto(s)
Fallo Renal Crónico/complicaciones , Ultrasonografía Doppler en Color , Ultrasonografía Doppler Dúplex , Enfermedades Vasculares/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Brazo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Flebografía , Valor Predictivo de las Pruebas , Diálisis Renal , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
PURPOSE: Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function. METHODS: One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty. RESULTS: Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored (p = NS). The postoperative graft function rate was significantly better in the surgical group (p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis (p < 0.05). CONCLUSIONS: Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops.
Asunto(s)
Angioplastia de Balón , Derivación Arteriovenosa Quirúrgica/efectos adversos , Oclusión de Injerto Vascular/terapia , Diálisis Renal/efectos adversos , Trombectomía , Trombosis/terapia , Angioplastia de Balón/economía , Angioplastia de Balón/métodos , Angioplastia de Balón/estadística & datos numéricos , Derivación Arteriovenosa Quirúrgica/economía , Derivación Arteriovenosa Quirúrgica/estadística & datos numéricos , Terapia Combinada , Costos y Análisis de Costo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diálisis Renal/economía , Diálisis Renal/estadística & datos numéricos , Stents , Trombectomía/economía , Trombectomía/métodos , Trombectomía/estadística & datos numéricos , Factores de Tiempo , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To evaluate the management and outcome of chronic atherosclerotic infrarenal aortic occlusion (IRAO), a review of 48 patients who were treated for angiographically documented IRAO between January 1980 and December 1994 was undertaken. Mean follow-up was 45 months. Mean age was 57 years (range, 33 to 88 years). Forty-seven patients were heavy smokers. Symptoms included claudication in 81%, rest pain in 25%, and tissue loss in 15%. Impotence was documented in 73% of men. Associated arterial disease included inferior mesenteric artery occlusion in 31 patients, renal artery stenosis or occlusion in 12, superior mesenteric artery stenosis in two, and celiac artery stenosis in one. METHODS: Forty inflow procedures were performed, including 17 thoracobifemoral bypass (TBF) procedures, 15 aortobifemoral/iliac bypass (ABFI) procedures, and eight axillobifemoral bypass (AXBF) procedures. Eight patients were managed without surgery. The thoracic aorta was chosen as the inflow source in 17 patients because of previous abdominal aortic surgery in eight, poor status of the abdominal aorta in eight, and horseshoe kidney in one. RESULTS: The overall operative mortality rate was 5%, and the perioperative morbidity rate was 18%. There was no statistical difference in perioperative mortality and morbidity rates among the operative groups. The five-year survival rate (life-table) for all IRAO patients was 67%. TBF and ABFI revascularization procedures yielded 5-year patency rates of 71% and 79%, respectively (p < 0.05). All eight patients who underwent AXBF died or had occluded grafts at 3 years after surgery. Two-year patency rates (life-table) for TBF, ABFI, and AXBF were 92%, 92%, and 44%, respectively. The AXBF patency rate was significantly inferior to those of TBF and ABFI (p < 0.05). Changes in ankle-brachial indexes after TBF or ABFI were similar, but were significantly greater than changes after AXBF (p < 0.05). Three patients in the nonoperative group died, and two underwent major amputation. Acute renal failure did not occur in our study population. Follow-up creatinine levels > 2.0 mg/dl were documented in three operative patients and in one nonoperative patient, and none required dialysis. CONCLUSIONS: In patients who have IRAO, aorta-based inflow procedures are superior to AXBF both in hemodynamic outcome and in patency rates. Treatment of IRAO with TBF or ABFI yields similar long-term results; the descending thoracic aorta represents an excellent inflow alternative to the abdominal aorta. Clinically significant renal impairment is rarely associated with IRAO. Nonoperative management of IRAO is associated with an increased mortality rate and a high rate of limb loss.
Asunto(s)
Enfermedades de la Aorta/cirugía , Arteriosclerosis/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Aorta Abdominal/cirugía , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico por imagen , Arteriosclerosis/complicaciones , Arteriosclerosis/diagnóstico por imagen , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Radiografía , Estudios Retrospectivos , Tasa de Supervivencia , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/métodos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
The objective of this study was to evaluate the effect of preeclampsia and its severity on maternal mean middle cerebral artery blood flow velocity (mean MCA-CBFV) using transcranial doppler sonography (TCD), as well as the effect of magnesium on mean MCA-CBFV in preeclampsia. This study used a prospective, comparative design. TCD was used to examine maternal mean MCA-CBFV in both healthy subjects (controls) and preeclamptic subjects (cases). The two groups were similar in age, gestational age, and parity. Healthy subjects were categorized into three groups: Group I, 6-14 weeks, n = 10; Group II, 24-40 weeks, n = 27; Group III, postpartum n = 15, 12-36 h. Serial TCD examinations of the middle cerebral artery were completed in 21 preeclamptic subjects at four different points in time: Time I is an initial measurement before delivery; Time 2 is also before delivery but after magnesium had been administered. Time 3 is postpartum while on magnesium (12-24 h), Time 4 is postpartum off magnesium, (24-48 h). Preeclamptic subjects had significantly increased mean MCA-CBFV when compared to healthy subjects: antepartum (mean 78.2 vs. 55.1 cm/sec, P < 0.0005); postpartum (mean 101.3 vs. 69.8 cm/sec, P < 0.0001). Severe preeclamptics had significantly higher mean MCA-CBFV than mild preeclamptics at each point in time: Time 1: P < 0.016; Time 2: P < 0.040; Time 3: P < 0.002; and Time 4: P < 0.028. These data support the theory that cerebral vasospasm of the smaller diameter vessels is a major component of preeclampsia.
Asunto(s)
Ataque Isquémico Transitorio/diagnóstico por imagen , Preeclampsia/fisiopatología , Ultrasonografía Doppler Transcraneal , Adulto , Velocidad del Flujo Sanguíneo , Arterias Cerebrales/diagnóstico por imagen , Arterias Cerebrales/fisiología , Arterias Cerebrales/fisiopatología , Diástole , Femenino , Hematócrito , Humanos , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/fisiopatología , Periodo Posparto , Preeclampsia/diagnóstico por imagen , Embarazo , Valores de Referencia , SístoleRESUMEN
PURPOSE: The purpose of this study was to review the various extrathoracic reconstruction options in patients with occlusive disease of the supraaortic trunks and to define the efficacy of these procedures in maintaining graft patency and relieving symptoms. METHODS: Forty-four consecutive patients underwent 47 extrathoracic bypass procedures of the supraaortic trunks for correction of symptomatic subclavian (SCA), common carotid (CCA) or innominate (INA) artery occlusive disease between July 1975 and May 1994. SCA stenosis (n = 27) was associated with upper extremity claudication (55%), vertebrobasilar insufficiency (15%), or both (30%). CCA stenosis (n = 14) was accompanied by hemispheric symptoms in 86% and global ischemia in 14%, whereas INA stenosis (n = 3) was associated with transient ischemic attacks (67%) and right arm ischemia (33%). RESULTS: SCA revascularization included carotid-subclavian or carotid-axillary bypass (n = 19), axilloaxillary bypass (n = 8), and subclavian-carotid transposition (n = 3). CCA reconstructions included subclavian-carotid (SC) bypass (n = 13) and carotid-carotid bypass (n = 1). INA procedures included three axilloaxillary bypasses. Six patients had an associated carotid endarterectomy, and three underwent concomitant vertebral artery transpositions. Intraluminal shunts were not routinely used. Vein was used as a conduit in five procedures, and a prosthetic graft (23 Dacron, 16 polytetrafluoroethlyene) was used in the remainder. The average postoperative intensive care unit and hospital and hospital stay were 1 and 5 days, respectively. Follow-up was available in 43 of 44 patients (mean = 26.2 months). The perioperative mortality rate was 2.2% (one axilloaxillary). There were five graft occlusions in procedures involving the axillary artery (3 of 11 axilloaxillary, 2 of 7 carotid-axillary) as compared with one of 29 thromboses when the operation was confined to the supraclavicular fossa (p < 0.05) Relief of symptoms was achieved in all patients with patent grafts. There were no perioperative strokes in the series. Other complications included one brachial plexus neuropraxia (axilloaxillary) and four patients with phrenic nerve neuropraxia. CONCLUSION: Extrathoracic revascularization of the supraaortic trunks is well tolerated and durable when operations are confined to the supraclavicular fossa and do not involve the axillary artery.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Tronco Braquiocefálico/cirugía , Arteria Carótida Común/cirugía , Arteria Subclavia/cirugía , Adulto , Anciano , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/mortalidad , Prótesis Vascular , Femenino , Humanos , Complicaciones Intraoperatorias , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Grado de Desobstrucción Vascular , Venas/trasplanteRESUMEN
PURPOSE: The purpose of this study was to review the treatment of patients with failed or infected axillofemoral bypass grafts and to determine the efficacy of remedial procedures in maintaining graft patency and limb preservation. METHODS: Thirty-four patients with 37 failed or infected axillofemoral grafts were retrospectively reviewed. In nine cases there was no attempt at revascularization, and in the remaining 28 cases, a total of 52 remedial procedures was performed. Nine were performed in patients with graft infection and 43 in patients with graft thrombosis. In patients with axillofemoral graft failure, 21 thrombectomies, 13 graft revisions, and 9 secondary reconstructions were performed. Eighty-eight percent of patients were monitored at least 2 years or until graft failure. RESULTS: Eight of nine patients receiving no remedial procedure required major amputation. The limb salvage rate was 64% +/- 11% at 30 months in the 25 patients undergoing remedial procedures. Twenty-eight percent of failed axillofemoral grafts remained patent at 2 years after initial failure with single or multiple thrombectomies or revisions. Life-table primary patency after secondary reconstructions (81% +/- 10.9% at 24 months) was significantly better than after thrombectomy alone (10% +/- 4.2% at 24 months) or graft revision (16% +/- 10.6% at 24 months) by log-rank test (p < 0.001 and p < 0.005, respectively). Patients undergoing reconstruction with descending thoracic aorta to femoral artery bypass had an 89% +/- 11% patency rate at 24 months. Graft infection resulted in a perioperative mortality rate of 22% and amputation in 57% of survivors. CONCLUSION: Axillofemoral graft failure most often results in limb loss without remedial procedures. Thrombectomy and revision procedures had poor long-term patency rates and salvaged only a minority of grafts despite multiple procedures. Reconstruction by use of an alternate source of inflow such as the descending thoracic aorta resulted in better long-term patency rates in patients well enough to tolerate a major reoperative procedure.
Asunto(s)
Arteria Axilar/trasplante , Prótesis Vascular , Arteria Femoral/trasplante , Oclusión de Injerto Vascular/cirugía , Pierna/irrigación sanguínea , Pierna/cirugía , Infecciones Relacionadas con Prótesis/cirugía , Trombosis/cirugía , Amputación Quirúrgica , Aorta Torácica/cirugía , Arteria Axilar/fisiopatología , Femenino , Arteria Femoral/fisiopatología , Estudios de Seguimiento , Oclusión de Injerto Vascular/complicaciones , Oclusión de Injerto Vascular/mortalidad , Oclusión de Injerto Vascular/fisiopatología , Humanos , Tablas de Vida , Masculino , Persona de Mediana Edad , Necrosis , Dolor/etiología , Valor Predictivo de las Pruebas , Falla de Prótesis , Infecciones Relacionadas con Prótesis/complicaciones , Infecciones Relacionadas con Prótesis/mortalidad , Infecciones Relacionadas con Prótesis/patología , Reoperación , Estudios Retrospectivos , Trombectomía , Trombosis/complicaciones , Trombosis/mortalidad , Trombosis/patología , Trombosis/fisiopatología , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To evaluate the results of femorofemoral bypass graft (FFBPG), we analyzed 110 consecutive FFBPGs performed at our institution during an 11-year period. METHODS: In 62 (56%) patients the indication for surgery was claudication and in 48 (44%) patients rest pain or tissue loss. In 42 patients the superficial femoral artery (SFA) was occluded. A preoperative percutaneous transluminal balloon angioplasty (PTA) was performed in 24 (22%) patients to correct a significant donor iliac artery stenosis. In 48 (44%) patients a total of 54 arterial procedures were performed simultaneously with FFBPG. RESULTS: After surgery 75 (68%) patients were moderately or markedly improved, whereas 20 (18%) were minimally improved, unchanged, or worse, including 7 (6%) with hemodynamic failures. The in-hospital mortality rate was 4.5%. Actuarial patient survival rate was 70% +/- 8.6% at 6 years. The actuarial primary graft patency rate was 83% +/- 4.2% at 1 year, 71% +/- 6.9% at 3 years, 60% +/- 8.3% at 5 years, and 51% +/- 9.6% at 6 years. Age, sex, and race of the patient did not influence graft patency. Grafts placed for limb-threatening ischemia or in patients with SFA occlusion had a similar patency rate compared with those placed for claudication or in patients with patient SFA. The overall limb preservation rate was 83% +/- 7.3% at 5 years but was only 64% for patients who underwent operation for limb-threatening ischemia. CONCLUSIONS: In conclusion, FFBPG offers moderately low long-term patency in a population with limited survival. Outflow procedures performed concomitantly with FFBPG seemed to compensate for the negative impact on graft patency rate of ipsilateral SFA occlusion and limb-threatening ischemia. Limb-threatening ischemia, however, carried a significantly higher (p < 0.05) amputation rate. The influence of preoperative donor iliac artery percutaneous transluminal balloon angioplasty on FFBPG patency remains unclear.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Prótesis Vascular , Arteria Femoral/cirugía , Isquemia/cirugía , Pierna/irrigación sanguínea , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/mortalidad , Arteriopatías Oclusivas/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Isquemia/mortalidad , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Tereftalatos Polietilenos , Politetrafluoroetileno , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Progression of distal disease is considered the most common cause of femorofemoral artery crossover bypass graft (FFBPG) failure. Twenty-seven patients with patient grafts (mean 53 months) were evaluated with segmental Doppler and duplex scan arterial studies for evidence of disease progression. In the early postoperative period (compared with preoperative levels), 26 patients (95.3%) showed a significant improvement (> 0.1) in the recipient limb ankle-brachial index (ABI) (mean increase of 0.38; SD = 0.24) and/or ankle spectral arterial waveform. However, there was a statistically significant decrease (p = 0.0001) in the donor limb ABI, and 12 patients (44.4%) had a > 0.1 deterioration. On long-term follow-up (compared with preoperative levels) this difference was no longer significant (p = 0.49); only seven donor limbs remained with a > 0.1 decrease in ABI. The recipient limbs maintained a significant improvement (> 0.1) in the ABI compared to preoperative levels (p < 0.0001; mean of 0.39; SD = 0.16) except for three limbs that had decreased by 0.1. However, eight patients (29.6%) developed an increase in their donor common femoral artery acceleration time > 133 msec and/or increased blood flow velocity without a simultaneous significant decrease in their recipient limb ABI. In the latter group the preoperative donor limb common femoral artery acceleration time and ABI and the immediate postoperative change in donor limb ABI were not significantly different (p > 0.05) than in the remaining patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Arteria Femoral/trasplante , Oclusión de Injerto Vascular/diagnóstico , Arteriopatías Oclusivas/cirugía , Velocidad del Flujo Sanguíneo , Femenino , Humanos , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , RecurrenciaRESUMEN
In patients with superficial femoral artery obstruction, iliac disease may be difficult to diagnose by commonly used noninvasive techniques. We studied common femoral artery acceleration time (onset of systole to peak systole), as measured from a Doppler spectral display and expressed in milliseconds. Previous work has suggested that an acceleration time of 144 msec or greater is abnormal and is associated with iliac stenosis (greater than or equal to 75% diameter reduction) or occlusion. During a 2-year period, in 139 limbs with superficial femoral artery obstruction, acceleration times were measured immediately before angiography. The overall test accuracy was 94.2% (131/139). In the 112 sides with normal angiograms, the acceleration time correctly identified no disease in 109 patients (97.3% specificity), and in the 27 iliac stenoses or occlusions the test detected disease in 22 patients (81.5% sensitivity). This appears to be a good test that can be done with equipment usually available in most vascular laboratories.
Asunto(s)
Arteriopatías Oclusivas/diagnóstico por imagen , Arteria Femoral/diagnóstico por imagen , Arteria Ilíaca/diagnóstico por imagen , Angiografía , Arteriopatías Oclusivas/epidemiología , Velocidad del Flujo Sanguíneo/fisiología , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/epidemiología , Humanos , Valor Predictivo de las Pruebas , Curva ROC , Sensibilidad y Especificidad , Ultrasonido , UltrasonografíaRESUMEN
During the last 3 decades subcutaneous extraanatomic bypass, despite its limited durability, has been the favored alternative to infrarenal aortofemoral bypass. Meanwhile, the descending thoracic aorta has been scarcely used as an inflow source for aortoiliac reconstruction. Over the past 8 years we performed 16 bypasses from the descending thoracic aorta to the iliofemoral vessels for occlusive disease. Our experience combined with that found in the English-language literature totaled 141 patients. In 79 patients (56%) the indication for surgery was failure or infection of an abdominal aortofemoral graft. Previous abdominal operations, sepsis, radiation therapy, the presence of abdominal stomas, or an unsuitable infrarenal aorta were the indications in the remaining cases. The combined operative mortality rate was 6.4%. The life-table primary graft patency was 98% at 1 year, 88% at 2 years, and 70.4% at 5 years. Bypass from the descending thoracic aorta to the iliofemoral artery uses an inflow source superior to other extraanatomic reconstructions, does not require aortic cross-clamping, avoids the abdominal cavity, and places the graft remote to the skin and intestine. The operative mortality and patency rates compare favorably to those of other extraanatomic or remedial aortic reconstructions. Descending thoracic aorta to iliofemoral artery bypass is a superb alternative to abdominal aortofemoral bypass, carries a low mortality rate, has an excellent short-term patency, and features unique characteristics for long-term durability.
Asunto(s)
Aorta Torácica/cirugía , Arteriopatías Oclusivas/cirugía , Arteria Femoral/cirugía , Arteria Ilíaca/cirugía , Pierna/irrigación sanguínea , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Arteriopatías Oclusivas/fisiopatología , Prótesis Vascular , Femenino , Humanos , Tablas de Vida , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional , Estudios Retrospectivos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
Injury to the stump of a below-knee amputation (BKA) may require revision to a higher level of amputation. We undertook a retrospective review of BKAs performed during a 14-year period. Twenty-three patients suffered trauma to their stumps. Most (80%) trauma resulted from a fall. The severity of the trauma was graded on a three-part scale. Operative reclosure was attempted in 8 cases with 2 successes. Closure by secondary intent was successful in 7 of the 12 attempts. A total of 11 patients had revision to above-knee amputation (AKA) as the final outcome. The severity of trauma correlated inversely with the likelihood of eventual stump salvage. We conclude that primary reclosure or closure by secondary intent should be considered, since in 53% of attempts this results in knee preservation. Analysis of noninvasive vascular testing prior to the BKA was not helpful in predicting successful salvage of traumatized stumps.
Asunto(s)
Muñones de Amputación , Accidentes por Caídas , Femenino , Humanos , Rodilla , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Dehiscencia de la Herida Operatoria/etiología , Dehiscencia de la Herida Operatoria/cirugía , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
Quantitative fluorometry has been recommended as an accurate adjunct to clinical judgment in the preoperative assessment of lower-extremity amputation level. In this prospective study of 56 patients who had below-knee amputation, clinical judgment was used as the sole criterion for site selection. Quantitative fluorometry was compared with clinical judgment in a prospective, blinded study. All patients were studied before amputation with administration of intravenous fluorescein. Fifteen minutes after injection, objective measurement of dye fluorescence was performed at multiple sites with a quantitative fluorometer, and a dye fluorescence index was derived. All limbs undergoing amputation were ischemic, manifested by rest pain, nonhealing ulcers, or gangrene. Five patients (8.7%) failed to heal at the below-knee level. The mean dye fluorescence index for the group that healed was 81 +/- 51 (range, 13 to 259) and for the group that failed to heal, 110 +/- 49 (range, 70 to 195). Objective measurement of fluorescein perfusion did not correlate with amputation healing at the below-knee level in our patient population.
Asunto(s)
Amputación Quirúrgica , Fluorometría , Rodilla/cirugía , Pierna , Piel/irrigación sanguínea , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Fluoresceínas , Fluorometría/métodos , Humanos , Pierna/cirugía , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Probabilidad , Estudios Prospectivos , Método Simple Ciego , Cicatrización de HeridasRESUMEN
Various tests are used preoperatively to differentiate patients who require an above-knee amputation (AKA) from those whose vascular supply is adequate to heal a below-knee procedure (BKA). This 15-month study of 109 amputations compared four of these methods: segmental Doppler systolic pressure measurements, transcutaneous oxygen measurement (tcPO2), fluorescein angiography, and skin thermometry. There were 66 BKAs (85% healed primarily) and 43 AKAs (93% healed primarily). The actual level of amputation was determined by the operating surgeon without consideration of the preoperative test results, and the incidence of healing was then related to the test parameters. The average skin temperature at the amputation site was higher (93.7 degrees F) in the group that healed primarily compared with those who required operative stump revision (89.9 degrees F) (p less than 0.001). The mean midcalf tcPO2 was also higher in the BKA group that healed (PO2 = 36.6 mm Hg) compared with those who failed (PO2 = 16.4 mm Hg) (p less than 0.001). Qualitative skin fluorescence was less successful in differentiating success from failure. Of the 63 BKAs that fluorescein predicted would heal, eight failed (13%). Doppler pressures at the thigh, popliteal, midcalf, or ankle level were unreliable in predicting healing of a BKA. Formulation of indexes relating absolute pressures to the brachial systolic pressure did not improve the value of this examination. From this review it is concluded that the skin temperature and tcPO2 obtained at the site of proposed amputation were the most reliable prognostic noninvasive examinations.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Amputación Quirúrgica , Pierna/cirugía , Cicatrización de Heridas , Anciano , Circulación Sanguínea , Presión Sanguínea , Femenino , Humanos , Pierna/irrigación sanguínea , Pierna/fisiopatología , Masculino , Persona de Mediana Edad , UltrasonografíaRESUMEN
We evaluated the microbiologic nature of aneurysm contents. Aerobic and anaerobic cultures were taken from non-blood fluid, laminar thrombus, or ulcerated plaque within aortic aneurysms operated on during an eight-year period. Positive bacterial cultures were obtained from 22 (10.4%) of 211 aneurysms. Staphylococcus epidermidis was the most common organism recovered (12/22, 54%). Bacterial colonization of the arterial wall has a possible role in the pathophysiology of prosthetic graft sepsis. These data are valuable not only in choosing appropriate prophylactic antibiotics for aneurysm repair, but also in experimental efforts to develop an infection-resistant vascular graft by directing the antimicrobial characteristics of agents selected for binding to various prosthetic flow surfaces.
Asunto(s)
Aneurisma de la Aorta/microbiología , Infecciones Bacterianas/etiología , Prótesis Vascular , Complicaciones Posoperatorias/etiología , Aorta Abdominal/microbiología , Aneurisma de la Aorta/cirugía , Estudios de Seguimiento , Haemophilus influenzae/aislamiento & purificación , Humanos , Salmonella/aislamiento & purificación , Staphylococcus epidermidis/aislamiento & purificación , Infección de la Herida Quirúrgica/etiologíaRESUMEN
This article reports the results of a multicenter study that compares 333 frequency analysis studies with the continuous-wave Doppler method with angiography. With receiver operating characteristic curves, the study documents the accuracy of the Doppler technique for the diagnosis of extracranial carotid arterial stenosis greater than 45% diameter reduction. It confirms the accuracy of the measurement of the maximal peak Doppler frequency and, in addition, shows that quantitative analysis of the instantaneous Doppler spectrum at peak systole by the measurement of the spectral broadening index is of diagnostic value. Likelihood ratios have been calculated with the use of curve-fitting techniques and it has been demonstrated how both the peak frequency and the spectral broadening index can be used together to improve the certainty of diagnosis. It is concluded that the probability that an individual patient has significant carotid arterial disease can be determined with the measurements of peak frequency and spectral broadening index from the continuous-wave Doppler spectral waveform.
Asunto(s)
Enfermedades de las Arterias Carótidas/diagnóstico , Ultrasonografía/métodos , Arterias Carótidas/diagnóstico por imagen , Estudios de Evaluación como Asunto , Humanos , Radiografía , Ultrasonografía/instrumentaciónRESUMEN
Although various techniques to determine amputation level have become available, obvious clinical factors may yet identify patients in whom a major amputation is unlikely to heal. We have analyzed the association of multiple clinical factors with the morbidity of 1028 consecutive amputations performed in 786 patients during a 13-year period. The overall operative mortality rate was 7% (57 of 786 patients). Cardiac complications were the leading cause of death (43%). In the 729 patients surviving operation, 345 above-knee amputations (AKAs) and 626 below-knee amputations (BKAs) were performed. After operation, 15.4% of these amputations failed to heal and required proximal revision. The AKA failure rate was 9% and the BKA failure rate was 19%. Significantly higher failure rates were noted in whites, nondiabetics, and those patients with heart disease. It is concluded that major amputation continues to be associated with significant morbidity and mortality rates despite changes in perioperative care and surgical technique. Common clinical characteristics indicate high-risk patients in whom a BKA is unlikely to heal and who may benefit from prospective attempts to determine amputation level.