Faculty Bibliography

OBJECTIVES: Vascular malformations of the pelvis are rare and present a difficult therapeutic challenge. Surgical treatment is notoriously difficult and carries a high likelihood of recurrence. Surgical proximal ligation of a feeding vessel may in fact be contraindicated, because it can make subsequent transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic complex pelvic vascular malformations in 35 patients. METHODS: A retrospective review was conducted of a prospectively compiled database of all patients undergoing transcatheter therapy of a pelvic vascular malformation at our institution. RESULTS: The mean age of the patients was 34 years (range, 16 months-66 years), and 51% were male. The most common presenting symptoms included pain (59%), a visible or palpable lesion (62%), associated palpable pulsation or thrill (44%), hemorrhage (27%), congestive heart failure (18%), and symptoms due to mass effect (35%). A significant number of patients had undergone previous, unsuccessful attempted surgical treatment of the lesion (32%). The most common type of lesion noted on arteriography was arteriovenous shunting (89%). Patients required a mean of 2.4 embolization procedures (range, 1-11 procedures) over a mean period of 23.3 months (range, 1-144 months). The most common agents used were rapidly polymerizing acrylic adhesives. The most common vessels involved and treated were branches of the hypogastric artery (82%). More than one procedure were performed in 20 patients (53%). Seven were planned as staged embolizations, whereas 13 were due to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization therapy in five patients (15%). Eighty-three percent of patients were asymptomatic or significantly improved at a mean follow-up of 84 months (range, 1-204 months). CONCLUSIONS: Pelvic vascular malformations are difficult to eradicate completely, and recurrences are common. Many patients require multiple therapeutic interventions. However, most of these difficult cases have good results in the long term. Transcatheter embolization plays a significant role in, and may be the treatment of choice for, symptomatic pelvic vascular malformations

PURPOSE: When managing a new neurologic deficit after carotid endarterectomy (CEA), the surgeon is often preoccupied with determining the cause of the problem, requesting diagnostics tests, and deciding whether the patient should be surgically reexplored. The goal of this study was to analyze a series of perioperative neurologic events and to determine if careful analysis of their timing and mechanisms can predict which cases are likely to improve with reoperation. METHODS: A review of 2024 CEAs performed from 1985 to 1997 revealed 38 patients who manifested a neurologic deficit in the perioperative period (1.9%). These cases form the focus of this analysis. RESULTS: The causes of the events included intraoperative clamping ischemia in 5 patients (13.2%); thromboembolic events in 24 (63.2%); intracerebral hemorrhage in 5 (13.2%); and deficits unrelated to the operated artery in 4 (10.5%). Neurologic events manifesting in the first 24 hours after surgery were significantly more likely to be caused by thromboembolic events than by other causes of stroke (88.0% vs. 12.0%, P<.002); deficits manifesting after the first 24 hours were significantly more likely to be related to other causes. Of 25 deficits manifesting in the first 24 hours after surgery, 18 underwent immediate surgical reexploration. Intraluminal thrombus was noted in 15 of the 18 reexplorations (83. 3%); any technical defects were corrected. After the 18 reexplorations, in 12 cases there was either complete resolution of or significant improvement in the neurologic deficit that had been present (66.7%). CONCLUSIONS: Careful analysis of the timing and presentation of perioperative neurologic events after CEA can predict which cases are likely to improve with reoperation. Neurologic deficits that present during the first 24 hours after CEA are likely to be related to intraluminal thrombus formation and embolization. Unless another etiology for stroke has clearly been established, we think immediate reexploration of the artery without other confirmatory tests is mandatory to remove the embolic source and correct any technical problems. This will likely improve the neurologic outcome in these patients, because an uncorrected situation would lead to continued embolization and compromise

A 43-year-old woman presented with symptomatic mesenteric ischemia caused by median arcuate ligament compression of her celiac artery. Magnetic resonance angiography clearly demonstrated stenosis of the proximal celiac artery. She underwent laparoscopic decompression by division of the Ligament and excision of the celiac plexus. Laparoscopic Doppler ultrasound scanning demonstrated markedly improved now in the artery. She was discharged in 15 hours and reported complete resolution of her symptoms at the 3-month postoperative visit. Laparoscopy provides a less invasive but equally effective method for decompressing the celiac artery as well as assessing adequacy of flow after its release

The purpose of this study was to review a single-institution experience with the Endovascular Technologies [(EVT) Menlo Park, CA] transfemoral, endovascular system of abdominal aortic aneurysm repair. This study was performed at a medical center participating in the phase 1 and phase 2 evaluations of the EVT device. We reviewed the 25 cases performed at our institution. The patient population consisted of 21 males (84%) and 4 females (16%), with a mean age of 73.4 years. A total of eight tube grafts (32%) and 17 bifurcated grafts (68%) were attempted. Twenty-two of the twenty-five grafts were successfully implanted endovascularly (88%). Implantation failures were due to tortuosity or inadequate caliber of the iliac arteries, or incorrect positioning of the graft. The results show that endovascular repair of abdominal aortic aneurysms is an appropriate treatment for selected patients. Conversions to open repair have decreased as experience has grown; careful patient selection can minimize the number of unsuccessful implantations. Patient selection and accurate technique can also minimize the number of endoleaks

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

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

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

To assess the results of thrombolytic therapy and surgical decompression of the thoracic outlet in the management of spontaneous axillary vein thrombosis (AVT), the records of 38 patients at New York University Medical Center (NYUMC) with AVT were reviewed. Excluded from this report were 20 patients who had AVT secondary to an underlying medical condition, a subclavian catheter, or a failed dialysis access graft. Of the 18 remaining patients with no underlying medical condition, all were found to have effort-related axillo-subclavian thrombosis, Paget-Schroetter syndrome. Urokinase was used for thrombolysis in 17 of the 18 patients, (94.4%) with complete lysis in 14 (82.4%). The remaining patient received anticoagulation only following a favorable response to an initial heparin infusion. Of the patients achieving complete thrombolysis, all but one received urokinase within 8 days of the onset of symptoms. Clot lysis revealed axillary vein compression secondary to a thoracic outlet syndrome in 11 patients, and these underwent staged transaxillary thoracic outlet decompression by first rib resection. All 17 patients have been followed for a mean of 21 months, and none receiving lytic therapy have reoccluded. Review of these data confirms earlier reports showing that with early diagnosis, thrombolysis and, if indicated, thoracic outlet decompression, patients with spontaneous AVT can expect excellent clinical results with a good long-term prognosis