Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs.
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PURPOSE: The long-term patency for infrapopliteal bypass grafting with prosthetic material is less than optimal. Our experience demonstrates a 40% patency at 2 years for these grafts. Several adjuvant techniques have been developed to improve patency rates, two of which are a remote distal arteriovenous fistula and the creation of a distal vein cuff. This study summarizes our experience with these two techniques. METHODS: Between 1987 and 1998, 107 bypass graftings were performed to the below-knee popliteal or tibial vessels with the use of polytetrafluoroethylene. One group (48 bypass grafts) had polytetrafluoroethylene with adjuvant distal arteriovenous fistula (DAVF), and a second group (59 bypass grafts) was reconstructed with a distal vein cuff (DVC). The type of bypass grafting that was performed was based on surgeon experience and preference. Indications and demographics were similar in the two groups. All patients underwent the operation for limb-threatening ischemia, including gangrene (DAVF, 23%; DVC, 9%), ulceration (DAVF, 27%; DVC, 51%), and rest pain (DAVF, 50%; DVC, 40%). RESULTS: The primary patency rate was 48% and 38% at 3 years for DAVF and DVC, respectively. Secondary patency was 48% and 47% at 3 years, with limb salvage rates of 76% and 92% for DAVF and DVC, respectively (P <.05). Attempted thrombectomy without continuation of patency was undertaken in two patients with a failed DAVF. Attempts at restoration after thrombosis were made in eight patients with failed DVCs. Five patients underwent thrombectomy, of which four procedures were successful. Three patients had thrombolytic therapy, and two of these remained patent. CONCLUSION: Adjuvant techniques, including DAVF and DVC, produce acceptable long-term patency and limb salvage rates in bypass grafts performed to the below-knee popliteal and tibial vessels. This study suggests that DVCs may offer improved limb salvage rates and a greater opportunity for revision when bypass graft failure occurs. (+info)
Use of intraoperative monitoring with transcranial Doppler scanning during carotid endarterectomy has enabled identification of embolus signals in the ultrasound spectrum. Extension of this technique to preoperative screening has enabled identification of actively embolizing lesions and correlation with neurologic deficits. We report embolus signals in the peripheral circulation before operation, which aided diagnosis and decision to operate. The patient had been transferred from another institution after multiple revascularization procedures, including posterior tibial artery thrombectomy. Angiography performed on arrival at our institution confirmed an open bypass graft, although a small indentation was noted at the site of the previous posterior tibial artery thrombectomy. Runoff was intact to the plantar arch where there was attenuation of that vessel and occlusion of most digital branches. Duplex monitoring revealed no embolic signals in the graft or in the posterior tibial artery proximal to the previous arteriotomy. Distal to this site, embolic signals were detected. At the time of operation, a large platelet thrombus was identified at the site of the previous arteriotomy, and platelet thrombus was obtained from the plantar artery. It is concluded that doppler ultrasound scanning enables detection of peripheral embolization and the identification and location of lesions with such embolic activity. Diagnostic accuracy may be improved when there is clinical suspicion of embolization, enabling better patient selection for surgical procedures. This report provides the first clinicopathologic characterization of the emboli detected. (+info)
Polypoidal choroidal vasculopathy in exudative and haemorrhagic pigment epithelial detachments.
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AIMS: To determine the prevalence of polypoidal choroidopathy in consecutive patients presenting with large haemorrhagic and exudative neurosensory retinal and retinal pigment epithelial detachments (PEDs) of over 2 mm in diameter in the absence of drusen. METHODS: 40 patients were identified over a 5 month period of which 29 had haemorrhagic detachments, and 11 had purely exudative detachments. All had indocyanine green (ICG) angiography, and the presence was sought of large blood vessels in the choroid associated with localised dilated terminals that filled slowly and leaked ICG. RESULTS: In 34 cases (85%) there was an appearance consistent with previous descriptions of idiopathic polypoidal choroidal vasculopathy. Of the six without polypoidal lesions the disorder was attributed to choroidal neovascularisation in four, chorioretinitis in one, and a fibrovascular PED in one. Of those with polypoidal lesions 20 (65%) were female, the mean age was 65.4 years (range 44-88), and 25 (74%) were white, seven (20%) black, and two (6%) east Asian. Eight had a history of hypertension. Visual acuity varied from 6/6 to counting fingers in the involved eye (mean 6/24). Bilateral polypoidal choroidal lesions were demonstrated in 16 patients (47%). The predominant location for these lesions was the macular region in 23 patients (68%). Polypoidal vasculopathy was found in 16 patients (47%) who had a previous diagnosis of age related macular disease (AMD). No patients had evidence of intraocular inflammation. CONCLUSIONS: In a largely white patient population a high proportion of patients with haemorrhagic and exudative PEDs has evidence of polypoidal lesions on ICG angiography. (+info)
Projected workload for a vascular service in 2020.
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OBJECTIVE: to estimate the workload of a vascular service during the next two decades as the proportion of people aged over 65 years increases. METHODS: the study used the vascular registry data of Tampere University Hospital and the population data of Pirkanmaa region provided by the Central Statistical Office in Finland. The current workload is 1420 vascular procedures per million inhabitants yearly (951 surgical and 207 endovascular). Sixty-five per cent of all procedures are done on people over 65 years old. Pirkanmaa has a population of 440 000 persons of whom 15.6% are over 65 years. According to the population data the population will increase to 460 000 persons by the year 2020 and 22.9% of them will be over 65 years old. RESULTS: The total amount of procedures will rise by 40.5% (1906) and the increase in endovascular and surgical group will be 39.2% (640) and 43.5% (1265) respectively. The proportion of treated patients over 65 years will rise from 65.0% to 70.5%. In the next two decades the amount of patients with claudication will increase by 35.4%, critical limb ischaemia by 44.2%, carotid surgery by 34.0%, abdominal aortic aneurysms by 40.7%, acute limb ischaemia by 45.0% and access surgery by 27.4%. CONCLUSION: In the next two decades the number of elderly people will increase so rapidly that, whatever happens to the incidence and prevalence of peripheral vascular disease, the workload for a vascular service will increase significantly. (+info)
Antiplatelet therapy and other interventions after revascularisation procedures in patients with peripheral arterial disease: a meta-analysis.
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OBJECTIVES: To evaluate the efficacy of conservative adjuvant therapy after revascularisation procedures in patients with peripheral arterial disease. DESIGN: meta-analysis. MATERIALS: English-language studies published from 1976 to 1997. METHODS: Reports on conservative therapies in patients with peripheral arterial disease after percutaneous transluminal angioplasty, endarterectomy, thromboendarterectomy or bypass grafting were eligible. Uncontrolled or retrospective studies, double reports or trials without clinical outcomes were excluded. Included studies were graded as level 1 (randomised and double- or assessor-blind), level 2 (open randomised), or level 3 (non-randomised comparative). (Loss of) patency, amputation, vascular events and mortality were the outcomes considered. When feasible, end-of-treatment results, either continuous or binary, were combined with appropriate statistical methods. RESULTS: Thirty-two studies were included. Compared to non-active control, aspirin with dipyridamole improved (loss of) patency (odds ratio (OR) 0.69, 95% confidence interval (CI), 0.53 to 0.90) and mortality (OR 0.80, 95% CI, 0.57 to 1.14); ticlopidine improved (loss of) patency (OR 0.53, 95% CI, 0.33 to 0.85) and amputation (OR 0.29, 95% CI, 0.08 to 1.01). Data on the effectiveness of vitamin-K inhibitors were not conclusive. CONCLUSIONS: Patients with peripheral arterial disease improve their outcome by receiving aspirin with dipyridamole or ticlopidine after a revascularisation procedure. (+info)
Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms.
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OBJECTIVE: The purpose of this study was to determine the incidence of femoral and popliteal aneurysms in men and women who have abdominal aortic aneurysms (AAAs) and to assess potential etiologic differences in patients with and without these lower extremity aneurysms. METHODS: We studied 313 consecutive patients with AAAs encountered from 1995 to 1998 who underwent prospective ultrasound scanning to detect the presence or absence of femoral and popliteal aneurysms. Patients with and without these extremity aneurysms were compared for differences in potential etiologic risk factors with each other and with a statewide population of patients with AAAs. RESULTS: A total of 51 femoral and popliteal aneurysms were encountered, all occurring in male patients. Among the 251 men with AAAs, the incidence of femoral or popliteal aneurysms was 14%, compared with 0% among the 62 women with AAAs (P <.01). A family history of aneurysmal disease was present in only one (3%) of the 36 men with these extremity arterial aneurysms, a significant finding (P <.01) when compared with the family history that was positive for aneurysmal disease in 14 women (23%). Peripheral arterial occlusive disease affected 14 (39%) of the 36 men with peripheral arterial aneurysms versus 20 (9%) of the 215 men without these aneurysms (P <.01). Most other etiologic variables studied proved not to be different among the various groups of patients examined. CONCLUSION: The incidence of femoral and popliteal aneurysms in persons with AAAs appears higher than that noted previously. Femoral and popliteal aneurysmal disease preferentially affects men; however, the basis for this sex difference is unknown. Few common etiologic factors differed between men with and without these extremity aneurysms. Most femoral and popliteal artery aneurysms in this study were undetectable on physical examination, suggesting that ultrasound scanning is appropriate in the recognition of peripheral aneurysms among men with AAAs. (+info)
Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral.
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OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed. (+info)
Clinical failure after percutaneous transluminal angioplasty of the superficial femoral and popliteal arteries.
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OBJECTIVE: Anatomic patency after percutaneous transluminal angioplasty (PTA) of the superficial femoral and popliteal arteries does not guarantee clinical success. The aim of this report is to determine the causes of clinical failure after PTA. METHODS: The records of all patients who have undergone PTA of the femoropopliteal arterial segment by our vascular group were retrospectively reviewed. Only patients with complete records and at least one postprocedure clinical and anatomic assessment within the same 30-day time interval were included. Success was defined according to the Society for Vascular Surgery/International Society for Cardiovascular Surgery Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures. Anatomic cumulative patency and clinical success were calculated according to life table analysis on an intent-to-treat basis. RESULTS: We identified 85 patients who met inclusion criteria. We treated 112 lesions with an average stenosis of 80% +/- 16% and lesion length of 2.3 +/- 1.8 cm. Technical failure occurred in six (5.4%) of 112 lesions. Cumulative clinical success was 69% at 1 year, 54% at 2 years, 49% at 3 years, and 40% at 4 years. Anatomic patency was 74% at 1 year, 62% at 2 years, 57% at 3 years, and 52% at 4 years. There were 45 clinical failures; of these, twenty-seven (60%) occurred in conjunction with anatomic failure. Anatomic failure was due to restenosis in 12 patients (44%), occlusion in eight patients (30%), and restenosis with progression of disease in six patients (22%). Anatomic failure at the time of the procedure occurred in one patient (4%). Clinical failure occurred despite anatomic patency in the remaining 18 patients (40%). Etiology for clinical failure in this latter group included progression of disease within the treated vessel in 12 patients (67%), iliac disease in three patients (17%), tibial disease in two patients (11%), and bypass graft failure in one patient (5%). Fifty percent of all 45 clinical failures were successfully treated with supplemental percutaneous procedures. CONCLUSION: A PTA is an acceptable therapeutic option for the treatment of focal occlusive disease of the femoropopliteal arterial segment. Most clinical failures were due to anatomic failure, but a significant number occurred despite patency at the PTA site. Although primary clinical success rates were inferior to surgical bypass graft, supplemental PTA was possible in 50% of patients. Repeat percutaneous treatment may extend the interval of clinical success and may obviate the need for surgical bypass graft. (+info)