Faculty Bibliography

PURPOSE: The morbidity and clinical outcome of the failure to successfully repair an abdominal aortic aneurysm with Endovascular Technologies (EVT) grafts, resulting in explantation of the device, was assessed. METHODS: The records of all patients worldwide undergoing attempted endovascular repair with EVT devices from February 1993 to October 1997 were retrospectively reviewed. Of 669 patients, 19 (3%) were converted to open procedure with immediate explantation during the initial attempt at endovascular repair, and 27 patients (4%) required explantation at a later date, ranging from 1 day to 40 months. The incidence, morbidity, mortality, and effect on clinical outcome were evaluated. RESULTS: Causes of immediate conversion with explantation were: inaccurate deployment of the proximal or distal attachment systems (11 of 19; 58%); twists in the system (3 of 19; 16%); mechanism malfunction during deployment (4 of 19; 21%); and an aortic tear (1 of 19; 5%). Among the 27 patients undergoing late explantation, 20 (74%) did so because of persistent endoleaks. Three cases (11%) were performed because of aneurysm rupture, three (11%) because of graft occlusion, one because of aortic dissection (4%), and one (4%) because of graft migration into the aneurysm sac. The overall perioperative mortality rate was 11% (2 of 19) for immediate explantation and 7% (2 of 27) for late explantation. The average length-of-stay was 11 days for immediate explantation and 14 days for late explantation (NS). Complications included myocardial infarction (4%), pulmonary insufficiency (13%), wound infection (4%), and permanent renal failure (2%). There were no significant differences in the incidence rates of these complications between immediate and late explants. No cases of limb loss occurred. Median American Society of Anesthetists (ASA) classification was 3, and there was no correlation between ASA classification and mortality rate. Average operating time was 374 minutes for immediate explantation (including the time for the failed endovascular procedure) and 185 minutes for late explantation. CONCLUSION: Immediate and late explantation are infrequent events, occurring in 3% and 4%, respectively, of attempted EVT endovascular aortic stent placements. The mortality rate was higher for both immediate (11%; P <.05) and late (7%; NS) explantation when compared with the mortality rate of all patients undergoing EVT aortic endograft placement (1.5%). There does not appear to be increased long-term morbidity among patients undergoing successful explantation. Early recognition of the need to convert to open procedure, device improvement, and increased operator experience should continue to minimize the incidence of immediate and late explantation and their associated complications

OBJECTIVE: The ideal method of arterial reconstruction in operations for recurrent carotid disease after prior endarterectomy is unknown. The goal of this study was to review a series of carotid reoperations and to determine whether the surgical technique influenced the rate of perioperative stroke, late stroke, or secondary restenosis. METHODS: A retrospective review was conducted of 82 carotid reoperations performed on 74 patients at our institution. RESULTS: The patient population included 39 men (52.7%) and 35 women (47.3%), with a mean age of 67.5 years. The indications for redo surgery included transient ischemic attack or amaurosis fugax in 35.3% of the patients, stroke in 6.1%, and asymptomatic restenosis (>80%) in 58.5%. Patch angioplasty with or without redo endarterectomy was used in 47 cases (57.3%), with saphenous vein in 26 (31.7%), Dacron in 15 (18.3%), and polytetrafluoroethylene in 6 (7.3%). Interposition grafting was used in 35 cases (42.7%), with saphenous vein in 9 (11.0%), Dacron in 10 (12.2%), and polytetrafluoroethylene in 16 (19.5%). The perioperative complications included three strokes (3.7%). There was a trend toward increased perioperative neurologic complications with interposition grafting when compared with patch angioplasty (8.6% vs 2.1%), although this did not reach statistical significance. Long-term clinical follow-up was obtained in all cases with a mean duration of 35 months, with follow-up duplex scanning performed in 89.2%. The late failures of redo surgery included four significant secondary restenoses and five total occlusions. There was a trend towards improved long-term results with interposition grafting as opposed to patch angioplasty. However, the cases in which reconstruction was performed with a vein had a significantly higher rate of late failures (stroke, secondary recurrent stenosis, or occlusion) than those in which reconstruction was performed with any prosthetic material (26.7% vs 2.3%; P =.002 by Fisher exact test). CONCLUSION: The use of autologous material for redo carotid surgery in any configuration appears to significantly increase the rate of subsequent recurrent stenosis or total occlusion of the operated artery. The reason for this finding is unclear but may be related to both host and technical factors. Prosthetic material may be more durable in the long-term for redo carotid surgery. Interposition grafting for redo carotid surgery may increase the perioperative neurologic complication rate to some degree; however, this was not statistically significant in this series. Interposition grafting may be a more durable solution in long-term follow-up than redo endarterectomy and patch angioplasty. A longer follow-up period will be needed to confirm this conclusion

This article addresses the indications for surgical procedures and the anatomic relationships that must be imaged to effectively plan surgical intervention. Treatment and imaging of aortic aneurysm, aortic dissection, splanchnic artery aneurysms, renal artery disease, and arterial disease of the lower extremities are reviewed

It has been suggested that general anesthesia is the preferred method for reoperative carotid surgery for several reasons, including: the difficulty of the reoperative dissection; the disease may extend unusually high into the internal carotid artery; and the reconstruction required may be more complex than a typical endarterectomy. The purpose of this study is to show that reoperative carotid surgery can be performed safely under regional anesthesia. The records of 109 reoperative carotid operations performed on 96 patients over the past 25 years were reviewed. Procedures performed under regional anesthesia were compared to those performed under general anesthesia with respect to patient characteristics, intraoperative courses, and perioperative results. Regional anesthesia was utilized in 79 operations (72.5%); 30 operations were performed with general anesthesia (27.5%). The two patient groups were essentially equivalent with regard to atherosclerotic risk factors, preoperative neurologic symptoms, and the prevalence of contralateral total occlusion. The etiologies for recurrent disease included recurrent atherosclerosis (50.4%), intimal hyperplasia (30.3%), and vein patch aneurysm (9.2%). The methods of reconstruction employed included saphenous vein patch (47.7%), vein interposition graft (11.9%), prosthetic patch (20.2%), and prosthetic graft (20.2%). Perioperative strokes occurred in one case performed under regional anesthesia (1.3%), and in two cases under general anesthesia (6.6%); this difference was not statistically significant. Reoperative carotid artery surgery can be performed under regional anesthesia safely in the majority of instances. The aforementioned theoretical factors in favor of general anesthesia could also lead to technical difficulties with intraarterial shunt insertion. Having the patient awake, even if just long enough to prove that the patient will tolerate carotid artery clamping, might simplify many of these operations by avoiding shunt insertion. Regional anesthesia should therefore be considered an acceptable option in cases of reoperative carotid surgery

Retrograde aortic dissections can be a complication of vascular procedures. We describe a case of an inadvertent cannulation of the right common carotid artery during an attempt at inserting a pulmonary artery catheter. This resulted in dissection of the right common carotid, subclavian, and innominate arteries. Transesophageal echocardiography was able to visualize a retrograde dissection extending back into the ascending aorta

Vena caval thrombosis has posed a surgical therapeutic challenge for many years. Historically, spiral vein grafts and synthetic materials used as prostheses have had variable results. The use of the stent may serve as a more promising alternative when used in the capacity to relieve caval obstruction. A case is reported in which a young woman with Klippel-Trenaunay syndrome has exercise intolerance and associated hypotensive cardiovascular collapse caused by inferior vena caval thrombosis. Recanalization of her inferior vena cava was successfully achieved and subsequently maintained through the placement of two Wallstents across the lesion. Although most venous stenting procedures have thus far been used in the treatment of venous obstruction caused by malignancy, inferior vena cava stenting in this patient with inferior vena caval thrombosis and Klippel-Trenaunay syndrome suggests that venous stenting might offer an alternative therapeutic modality in treating a broader spectrum of occlusive venous disease

INTRODUCTION: While nonoperative management of blunt splenic injury in the stable patient has become the standard of care, splenectomy is still advocated as the safest management for rupture of the diseased spleen. The combination of splenectomy and underlying immunosuppression may render these patients particularly susceptible to postsplenectomy infection, and thus we undertook a prospective trial of nonoperative management of the ruptured pathologic spleen. METHODS: Hemodynamically stable patients with preexisting pathologic splenomegaly and isolated splenic disruptions diagnosed by computed tomographic (CT) scan (American Association for the Surgery of Trauma (AAST) grades 1-4) requiring 2 or less units blood transfusion were prospectively studied. Patients were monitored in a critical care setting, and resolution of splenic disruption was followed by serial CT examinations. RESULTS: Nonoperative management was successful in all 11 patients (eight, HIV/AIDS; one each, acute leukemia, infectious mononucleosis, sickle cell anemia). The mean transfusion requirement was 0.7 units; the mean length of stay was 16 days. CONCLUSIONS: The pathologic spleen can heal after parenchymal disruption. While not appropriate for all patients, a subset of hemodynamically stable patients can be successfully managed nonoperatively using CT diagnosis, close clinical monitoring, and minimal transfusions