Faculty Bibliography

Endovascular repair of aortic dissection is the subject of multiple studies. This article aims to review the current literature on Type B complicated and uncomplicated dissection, including indications for medical therapy, open surgical therapy, and endovascular therapy. The review suggests a benefit for thoracic endovascular aortic repair in complicated dissection and medical therapy for uncomplicated dissection. Upcoming trials may shed more light on this issue.

BACKGROUND:This study evaluated patients undergoing femoropopliteal bypasses using endoscopically harvested vein to treat Trans-Atlantic Inter-Society Consensus (TASC) stage D lesions. Primary patency and primary assisted patency were evaluated, as were perioperative morbidity and mortality and hospital length of stay (LOS). Results for this minimally invasive alternative to femoropopliteal bypass with conventional open vein harvesting were analyzed. METHODS:A retrospective analysis was performed on patients who underwent femoral-popliteal bypass with endoscopic saphenous vein harvest and angiographic TASC D anatomy. Postoperative duplex exams were evaluated, and the study end points of graft thrombosis or the development of a high-grade stenosis prompting reintervention were sought. Patient demographics, morbidity, mortality, and hospital LOS were analyzed. RESULTS:Twenty-seven patients meeting our inclusion criteria underwent surgery between June 2002 and June 2007. Indications for surgery in these patients were claudication (n=10), gangrene or ulceration (n=9), and ischemic rest pain (n=8). Fifty-two percent of the patients were male, 50% had cardiac disease, 65% had hypertension, 54% were diabetic, and 65% had a significant smoking history. Median LOS was 2.5 days in claudicants, 3.0 days in patients with rest pain, and 7.0 days in patients with gangrene or ulceration (p<0.05). Kaplan-Meier primary patency and primary assisted patency rates were 73.2% and 80.8% at 1 year, respectively; and these rates were maintained for 70 months. The only perioperative complication was a superficial wound infection, and two patients died during follow-up from causes unrelated to the surgery. CONCLUSION/CONCLUSIONS:Femoropopliteal bypass using endoscopic vein harvest is a durable reconstructive vascular procedure which can be performed with minimal postoperative morbidity, short LOS, and satisfactory long-term patency.

Portal venous aneurysms are rare and are usually discovered as incidental findings on abdominal imaging studies. Although most are asymptomatic, they may occasionally cause symptoms of compression of an adjacent structure, thrombosis, or bleeding. Treatment is usually not necessary and conservative follow-up is suggested. We present four patients with portal system aneurysms. One patient had a 10.5 cm thrombosed aneurysm, one had a right 3.5 cm intrahepatic portal aneurysm, one patient had a symptomatic 4 cm splenic artery aneurysm, which was repaired, and one patient had a 4 cm aneurysm at the confluence of the splenic and portal veins.

A 42-year-old woman developed right arm and right leg weakness when turning her head to the left. A carotid angiogram, in the neutral position, demonstrated anterior deviation of the left internal carotid artery and complete occlusion of the left internal carotid artery when the head was rotated to the left. During surgery, our patient had redundant left internal carotid artery and was treated by resection and reanastomosis of the internal carotid artery. The patient's Doppler 4 months postoperatively showed widely patent arteries, and she has subsequently been asymptomatic.

Mesenteric ischemia (MI) is caused by compromised blood flow to the arteries supplying the small and large intestine. Acute occlusive mesenteric ischemia (AMI) presents with the abrupt onset of severe abdominal pain, which if not diagnosed and treated immediately can cause bowel necrosis and prove fatal. Chronic occlusive mesenteric ischemia (CMI) is usually a longstanding process characterized by postprandial abdominal pain, progressive food intolerance, and weight loss. If untreated, CMI can lead to progressive disability and failure to thrive. This review article highlights the clinical and radiologic diagnosis of acute mesenteric ischemia and CMI and compares their treatment with surgical revascularization and the less invasive alternative of mesenteric artery angioplasty and stenting.

Limited information on a correlation between carotid stump pressure and cerebral oximetry changes associated with cross-clamping of carotid vessels during carotid endarterectomy (CEA) prompted us to prospectively evaluate 38 consecutive CEAs in 37 patients. The authors used the INVOS-4100 cerebral oximeter to measure cerebral oximetry (cerebral oxygen saturation) before (t1) and after (t2) cross-clamping along with carotid stump pressure. All patients had CEA under general anesthesia with the routine use of a Javid shunt. Cross-clamping (t1 vs. t2) resulted in statistically significant changes (p < 0.0001) on the operated side of 6.03 units or a percent change of 9.2% when analyzed using the nonparametric signed-rank test. The nonoperated side had insignificant change (p = 0.71). Spearman correlation analysis revealed significant correlation (r = -0.63) between cerebral oximetry changes on the operated side and carotid stump pressure such that a larger change in cerebral oximetry due to cross-clamping was strongly and significantly correlated with lower carotid stump pressure. Using regression analysis, stump pressures of 25 and 50 mm Hg were predicted by cerebral oximetry changes of 28.5 or 8.8 units, respectively. This is equivalent to a percent change from baseline (t1) of 41.1% or 13.1%, respectively. Taken together, these findings suggest that cerebral oximetry can be used as an alternative to carotid stump pressure to provide noninvasive, inexpensive, and continuous real-time monitoring during CEA.

Routine patch angioplasty after carotid endarterectomy (CEA) is believed to decrease the incidence of recurrent stenosis. The results of autogenous vein, Dacron, and PTFE used as a patch material have been described. Bovine pericardium has more recently been introduced as a patch material. We studied 61 of 73 consecutive patients who underwent isolated CEA with pericardial patch angioplasty to determine the incidence of restenosis and variables associated with restenosis. All patients had intraoperative completion duplex examination performed, and no patient had residual stenosis or anatomic defects at the end of the procedure. All procedures were performed under general anesthesia with the use of a Javid shunt. Mean age was 72.8 +/- 7.8 years, 41% were female, and 62% were asymptomatic. Hypertension was present in 72%, elevated cholesterol in 80%, and history of coronary artery disease in 44%. Recurrent stenosis of >50% was considered to be significant. Our study focuses on 61 of 73 patients who had follow-up duplex ultrasound data available. There were no perioperative neurologic events, reoperations for bleeding, or deaths. Mean duplex follow-up available in 61 patients was 13.1 +/- 5.1 months. Thirty-six patients had 1-15% stenosis, 15 patients had 16-49%, and 10 patients had 50-79%. In the 50-79% group, the mean systolic velocity was 154 +/- 25 cm/sec and the mean end diastolic velocity (EDV) was 36 +/- 16 cm/sec. The highest EDV in the 50-79% group was 56 cm/sec. No patients had stenosis in the 80-99% range. There were no late neurologic events and no late reinterventions. Kaplan-Meier restenosis-free survival at 1 year was 95.6%. Significant univariate predictors of recurrent stenosis of >50% were younger age (68 vs. 74 years, p = 0.04) and presence of preoperative symptomatic disease (35% vs. 5%, p = 0.004). Stepwise multiple logistic regression indicated the most significant predictor of restenosis was the presence of preoperative symptoms (p = 0.008). Stepwise Cox regression analysis also showed preoperative symptomatic status was the only significant factor for restenosis (p = 0.019), with a relative risk of 6.65 and a 95% confidence interval of 1.36-32.4. In conclusion, pericardial patch angioplasty is associated with minimal early adverse events. Restenosis with pericardial patch angioplasty is not uncommon, but high-grade restenosis did not occur in this study. The presence of preoperative symptoms and younger age were the most significant predictors of restenosis.

A rare presentation of arterial thoracic outlet syndrome (TOS) is described in a young woman. Arterial TOS caused by a cervical rib produced acute upper extremity ischemia due to subclavian artery aneurysm formation. Clinical presentation also included left hemiparesis caused by right subclavian artery thrombosis and retrograde embolization of thrombus via the common carotid artery to the right middle cerebral artery distribution. Surgical repair of the subclavian artery was performed, but permanent neurologic deficit remained. Acute thrombosis of the right subclavian artery can produce cerebrovascular complication. The assessment of such risk in patients with arterial TOS is warranted and the arterial lesion corrected surgically.

Popliteal artery aneurysms account for 85% of all peripheral aneurysms and are frequently associated with abdominal aortic aneurysms. Up to 75% of all popliteal artery aneurysms are discovered in symptomatic patients who present with arterial insufficiency, leg swelling, or pain. Popliteal artery aneurysms can be diagnosed with duplex ultrasonography. Aneurysm repair should be considered for all symptomatic patients with rest pain or limb-threatening symptoms. Asymptomatic aneurysms larger than 2 cm should also be treated to prevent the development of limb-threatening ischemia and assure better surgical bypass graft patency and longer freedom from amputation. Conventional aneurysm repair consists of either opening the aneurysm sac and interposing a bypass graft or aneurysm ligation combined with bypass grafting. If the aneurysm sac is left intact, side branch perfusion may persist and the aneurysm may continue to enlarge and can rupture. Endovascular popliteal aneurysm repair has not demonstrated clinical equipoise to standard surgery but may be advantageous in select high-risk patients.