Faculty Bibliography

PURPOSE: Occlusive disease of the aortoiliac segment may lead to limb-threatening ischemia, if coexisting disease is present in the femoral, popliteal, or tibial arteries. The combined treatment of severe aortoiliac and infrainguinal disease with standard techniques may be hazardous or contraindicated in patients with multiple previous reconstructions, severe comorbid medical illnesses, or both. This report summarizes the technical feasibility and early results of aortoiliac endovascular stented grafts (ESGs) in combination with conventional surgical reconstructions for the treatment of multilevel arterial occlusive disease. METHODS: Seventeen patients with multilevel aortoiliofemoral limb-threatening occlusive disease had an ESG inserted to treat long-segment occlusive disease followed by a conventional surgical bypass. ESGs originated from the aortoiliac junction (seven) or the common iliac artery (10) and were inserted into the common femoral (nine), superficial femoral (four), or deep femoral (four) artery. ESG lengths ranged from 16 to 30 cm (mean, 21 cm). Conventional surgical bypasses were constructed from polytetrafluoroethylene (15) or saphenous vein (two) and extended to the popliteal (12), tibial (two), or contralateral femoral (three) arteries. RESULTS: Technical success in graft insertion was achieved in 17 (94%) of 18 attempted ESG procedures. The 1-year primary and secondary cumulative patency rates for ESGs were 94% +/- 10% and 100%, respectively, whereas the 1- and 2-year patency rates for the extravascular grafts were 92% +/- 10% and 100%, respectively. Four patients had minor postprocedure complications (23%), and no deaths occurred. One patient lost his limb at 16 months because of severe pedal sepsis. CONCLUSIONS: Transluminally placed stented grafts in combination with conventional surgical infrainguinal bypasses are a technically feasible and potentially safe option for the treatment of limb-threatening aortoiliofemoral occlusive disease and have demonstrated encouraging early patency. Long-term follow-up will be necessary before widespread application of this technique is advocated

BACKGROUND: The patency of a saphenous vein graft is directly related to the quality of the vein harvested. Thus, appropriate evaluation of the vein before implanting it as a bypass graft may help identify those veins at high risk for early failure. Accordingly, we prospectively investigated whether prebypass angioscopic assessment of the saphenous vein could identify those vein grafts at particularly high risk of early failure. PATIENTS AND METHODS: Thirty-two greater saphenous veins with a grossly normal appearance were evaluated angioscopically before their use as a bypass conduit. After modification of abnormal segments, all of the veins irrigated well and were used as bypass grafts. RESULTS: Twenty-four patients were available for follow-up at 12 months. Seventeen (71%) had been prospectively classified as having angioscopically normal saphenous veins, while 7 were identified as having abnormal veins. The two groups did not differ significantly in demographics, cardiovascular risk factors, or indications for operative intervention. Twelve of the 17 (70%) normal veins were patent at 1 year; however, only 1 (14%) of the angioscopically abnormal vein grafts remained patent for 12 months (chi-square = 4.27; P = 0.039). CONCLUSION: Angioscopic inspection of the saphenous vein, before insertion as a graft, allows for identification of unrecognized venous disease that portends early graft thrombosis. Exclusion of abnormal veins, based on an abnormal angioscopic appearance, may lead to improved results for lower-extremity revascularization procedures; this supports the value of vein-graft angioscopy

PURPOSE: This report evaluates the application of transfemoral endovascular repair of iliac artery aneurysms. PATIENTS AND METHODS: Over a 20-month period, 11 patients with serious comorbid illnesses and a total of 14 iliac artery aneurysms were treated with endovascular grafts composed of polytetrafluoroethylene conduits combined with balloon expandable iliac artery stents (Palmaz). Nine right common, 3 left common, and 2 right internal iliac artery aneurysms were treated. The patients were men between 58 and 89 years of age (mean 72). Eight patients had isolated aneurysms and 3 had multiple iliac artery aneurysms. RESULTS: Endovascular iliac grafts were successfully placed in all 11 patients. No procedural deaths occurred. Follow-up ranged from 3 to 21 months (mean 11). No acute or late graft thromboses occurred. CONCLUSIONS: Transluminally placed endovascular stented grafts can be used to successfully exclude iliac artery aneurysms from the circulation while maintaining lower-extremity arterial perfusion. However, longer follow-up in more patients is necessary to confirm the durability of this technique

BACKGROUND: Initial antibiotic treatment of extracavitary arterial graft infections is usually empiric or based on Gram's stain findings. Increasing virulence of bacteria causing extracavitary arterial graft infections may render previous choices of antibiotics obsolete. The purposes of this study were to correlate Gram's stain findings of gram-positive bacteria and gram-negative bacteria with wound cultures and provide a microbiologic basis for appropriate initial antibiotic therapy. METHODS: Between July 1, 1979 and June 30, 1994, specimens obtained on the day of admission from purulent wounds involving 113 extracavitary arterial graft infections were retrospectively reviewed for Gram's stain and culture and sensitivity results. RESULTS: Gram's stain findings correlated with final cultures on only 28 of 113 cases (25%), including 20 of 48 pure gram-positive, 2 of 24 pure gram-negative, and 6 of 41 mixed bacterial cultures. Staphylococcus aureus was the most common gram-positive bacteria cultured (43 isolates) and Pseudomonas species was the most common gram-negative bacteria (25 isolates). Bacteria were sensitive to a first-generation cephalosporin in only 32% (36 of 113) of infections. A combination of vancomycin and either ticarcillin-clavulanic acid or ceftazidime, which have minimal toxicity and provide excellent coverage against staphylococci, Pseudomonas, and other gram-negative bacteria, would have covered 96% (109) and 95% (107) of cultured organisms, respectively. CONCLUSIONS: Regardless of Gram's stain findings, current recommendations for initial treatment of extracavitary arterial graft infections should include vancomycin and ceftazidime or ticarcillin-clavulanic acid until final culture and sensitivity results dictate the use of more selective antibiotics

Endovascular aortic graft implantation is a new procedure for the repair of arterial aneurysms. We report on the first such case successfully performed in the United States. A 76-year-old man with severe oxygen-dependent pulmonary insufficiency, coronary artery disease, and recurrent ventricular tachyrhythmia was also diagnosed as having a 7.5-cm infrarenal abdominal aortic aneurysm. Because of the high risks associated with conventional surgical repair, consent was obtained for compassionate use of an experimental device. Using local anesthesia, a 22-mm Dacron prosthesis was inserted under fluoroscopic guidance through an open, left transfemoral route. Completion arteriography demonstrated aneurysm exclusion. No blood transfusion was required and there were no perioperative complications. Further technical refinements and clinical trials will be required prior to the broad implementation of this technique