Angioplasty, Bypass and Invasive Procedures

Abou-Zamzam AM, Moneta GL, Lee RW, Nehler MR, Taylor LM and Porter JM: Peroneal bypass is equivalent to inframalleolar bypass for ischemic pedal gangrene. Arch Surg 131:894-899, 1966. Peroneal bypasses (159 patients) had similar intermediate-term survival, limb salvage and wound healing as inframalleolar bypasses (57 patients).
Albers M, Fratezi AC, De Luccia N: Assessment of quality of life of patients with severe ischemia as a result of infrainguinal arterial occlusive disease. J Vasc Surg 16:54-9, 1992. The purpose of this cohort study was to assess the quality of life of patients with severe ischemia as a result of infrainguinal arterial occlusive disease. Spitzer's QL-INDEX was selected to measure quality of life at baseline and at 3, 6, and 12 months. On the basis of initial treatment, 61 patients were grouped as follows: IC (conservative, n = 31), IR (arterial reconstruction, n = 14), and IA (major amputation, n = 16). After 12 months of follow-up, 48 patients were similarly regrouped according to ultimate treatment as follows: UC (n = 19), UR (n = 9), and UA (n = 20). At 12 months the mean score was significantly higher than the baseline in IC (6.43 vs 3.84, p less than 0.0001) as well as IR (5.64 vs 3.57, p less than 0.01), but not in IA (4.43 vs 3.62). The QL-INDEX mean score was lower in UA than in UC (4.15 vs 6.58, p less than 0.01) or UR (4.15 vs 7.11, p less than 0.0001). The correlation between QL-INDEX and an arbitrary scale was also high (r = 0.726, p less than 0.001). In conclusion, quality of life of patients with limb ischemia can be confidently assessed, improves during the first year of follow-up if major amputation is avoided, and improves and is sustained by a functioning graft. At baseline the mean QL-Index of 3.31 always close to the value of 3.31 achieved by 78 patients in critical or even terminal stages of cancer. 12 0f the 31 conservatively treated patients survived at least one year and 12 remained free of surgery. IC 3.84 to 5.15 to 6.32 to 6.43 (0, 3mo, 6mo, 12mo) IR 3.57 to 4.64 to 5.91 to 5.64 IA 3.62 to 3.62 to 4.13 to 4.43. Comments: It is to be appreciated that the conservatively-treated (a placebo-treated group from a surgical viewpoint) had a higher quality of life than the other groups at all time points throughout the study while the surgical group ended with the highest mean score. Something to be said for placebo care. Ideally, control-placebo groups should be included in all studies when feasible.
Adam DJ, Beard JD, Cleveland T et al: Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 366: 1925-34, 2005. BACKGROUND: The treatment of rest pain, ulceration, and gangrene of the leg (severe limb ischaemia) remains controversial. We instigated the BASIL trial to compare the outcome of bypass surgery and balloon angioplasty in such patients. METHODS: We randomly assigned 452 patients, who presented to 27 UK hospitals with severe limb ischaemia due to infra-inguinal disease, to receive a surgery-first (n=228) or an angioplasty-first (n=224) strategy. The primary endpoint was amputation (of trial leg) free survival. Analysis was by intention to treat. The BASIL trial is registered with the National Research Register (NRR) and as an International Standard Randomised Controlled Trial, number ISRCTN45398889. FINDINGS: The trial ran for 5.5 years, and follow-up finished when patients reached an endpoint (amputation of trial leg above the ankle or death). Seven individuals were lost to follow-up after randomisation (three assigned angioplasty, two surgery); of these, three were lost (one angioplasty, two surgery) during the first year of follow-up. 195 (86%) of 228 patients assigned to bypass surgery and 216 (96%) of 224 to balloon angioplasty underwent an attempt at their allocated intervention at a median (IQR) of 6 (3-16) and 6 (2-20) days after randomisation, respectively. At the end of follow-up, 248 (55%) patients were alive without amputation (of trial leg), 38 (8%) alive with amputation, 36 (8%) dead after amputation, and 130 (29%) dead without amputation. After 6 months, the two strategies did not differ significantly in amputation-free survival (48 vs 60 patients; unadjusted hazard ratio 1.07, 95% CI 0.72-1.6; adjusted hazard ratio 0.73, 0.49-1.07). We saw no difference in health-related quality of life between the two strategies, but for the first year the hospital costs associated with a surgery-first strategy were about one third higher than those with an angioplasty-first strategy. INTERPRETATION: In patients presenting with severe limb ischaemia due to infra-inguinal disease and who are suitable for surgery and angioplasty, a bypass-surgery-first and a balloon-angioplasty-first strategy are associated with broadly similar outcomes in terms of amputation-free survival, and in the short-term, surgery is more expensive than angioplasty.
Akbari CM, Pomposelli FB Jr, Gibbons GW, Campbell DR, Pulling MC, Mydlarz D, LoGerfo FW. Lower extremity revascularization in diabetes: late observations. Arch Surg 135: 452-6, 2000. HYPOTHESIS: Despite the success of infrainguinal arterial bypass in diabetic limb and foot salvage, optimism remains guarded because of purported high late mortality and limb loss in patients with diabetes. DESIGN: Inception cohort, with minimum 5-year follow-up. SETTING: Tertiary referral center. PATIENTS: Eight hundred forty-three consecutive patients undergoing lower extremity arterial reconstruction from July 1, 1990, through July 31, 1993. INTERVENTION: Infrainguinal arterial bypass with vein graft. MAIN OUTCOME MEASURES: Graft patency, limb salvage, and survival. RESULTS: A total of 962 vein grafts (843 patients) were performed; 795 grafts (82.6%) were performed in patients with diabetes (DM group) and 167 (17.4%) in nondiabetic patients (NDM group). Average age was 68.4 years, and was lower in the DM group (66.2 [range, 27-92 years] vs. 70.5 years [range, 37-96 years]) (P = .005). Inhospital 30-day perioperative mortality was 1.4%, lower in the DM group (0.9% vs. 4.2%) (P = .005). The target vessel was more frequently infrageniculate in the DM group (87% vs. 77%; P = .002). Five-year primary and secondary graft patencies were 74.7% (DM group, 75.6%; NDM group, 71.9%; P = .80) and 76.2% (DM group, 77.0%; NDM group, 73.6%; P = .90), respectively. The 5-year overall limb salvage rate was 87.1%, also unaffected by diabetes (DM group, 87.3%; NDM group, 85.4%; P = .80). Survival at 5 years was 58.1% overall and virtually identical in the DM (58.2%) and NDM groups (58.0%). CONCLUSIONS: Diabetes mellitus does not influence late mortality, graft patency, or limb salvage rates after lower extremity arterial reconstruction. Concern for longterm mortality and limb loss in diabetic patients is unwarranted and should not prevent aggressive attempts at limb salvage. See Voisine et al for gene differences in diabetics and non-diabetics undergoing cardiac surgery.
Arora S, Pomposelli F, LoGerfo FW, Veves A: Cutaneous microcirculation in the neuropathic diabetic foot improves significantly but not completely after successful lower extremity revascularization. J Vasc Surg 35:501-5, 2002. OBJECTIVE: The purpose of this study was the examination of the effect of successful large vessel revascularization on the microcirculation of the neuroischemic diabetic foot. RESEARCH DESIGN AND METHODS: We measured the cutaneous microvascular reactivity in the foot in 13 patients with diabetes with peripheral arterial disease and neuropathy (group DI) before and 4 to 6 weeks after successful lower extremity arterial revascularization. We also compared them with age-matched and sex-matched groups of 15 patients with diabetes and neuropathy, seven patients without neuropathy, and 12 healthy patients for control. We used single-point and laser Doppler scan imaging for the measurement of the foot skin vasodilatation in response to heating to 44 degrees C and to iontophoresis of 1% acetylcholine (endothelial-dependent response) and 1% sodium nitroprusside (endothelial-independent response). RESULTS: The group DI response to heat increased from 289% +/- 90% before surgery (percent increase over baseline measured in volts) to 427% +/- 61% (P <.05) after surgery but was still comparable with the response of the patients with diabetes and neuropathy (318% +/- 51%) and lower than the responses of the patients without neuropathy (766% +/- 220%) and the healthy patients for control (891% +/- 121%; P <.0001). The group DI acetylcholine response also improved from 6% +/- 4% before surgery to 26% +/- 8% after surgery (P <.05) and was similar to the responses of patients with diabetes and neuropathy (18% +/- 3%) and patients without neuropathy (38% +/- 8%) but still lower when compared with the response of the patients for control (48% +/- 9%; P <.001). The sodium nitroprusside response for group DI improved from 10% +/- 4% to 29% +/- 9% (P <.05) and was similar to the responses of the neuropathic (25% +/- 9%), nonneuropathic (32% plus minus 6%), and control (40% +/- 5%) groups. The group DI neurovascular response, which depends on the healthy function of the C-fiber nociceptors, was similar at baseline (5% +/- 9%) and after surgery (14% +/- %10) and in the neuropathic group (33% +/- 21%), but it was dramatically reduced when compared with the nonneuropathic (110% +/- 40%) and control (198% +/- 54%) groups (P <.001). CONCLUSION: Impaired vasodilation in the diabetic neuropathic lower extremity leads to functional ischemia, which improves considerably but is not completely corrected with successful bypass grafting surgery. Therefore, patients with diabetes and neuropathy may still be at high risk for the development of foot ulceration or the failure to have an existing ulcer heal despite adequate correction of large vessel blood flow.
Arafa OE, Pedersen TH, Svennevig JL, Fosse E, Geiran OR: Vascular complications of the intraaortic balloon pump in patients undergoing open heart operations: 15-year experience. Ann Thorac Surg 67: 645-51, 1999. Background. The beneficial effects of the intraaortic balloon pump (IABP) in providing circulatory support must be weighed against its complications, particularly its vascular trauma. Methods. Five hundred nine patients who underwent open heart operations at our institution and who were treated with the IABP from January 1980 through December 1994 were studied retrospectively to assess IABP-related vascular complications and their independent preoperative predictors and the implications of IABP-related vascular complications on the patients’ mortality, morbidity (clinical sepsis and organ failure), and long-term survival. Results. Early vascular complications occurred in 56 patients (11%) and major complications occurred in 41 patients (8%). The latter consisted of aortic perforation in 1 patient, aortoiliac dissection in 2 patients, and limb ischemia in 38 patients. Logistic regression analysis identified concomitant peripheral vascular disease (p < 0.001), elevated preoperative end-diastolic pressure, small body surface area, and large catheter size (p < 0.05) as independent risk factors for IABP-related major vascular complications in patients who survived the day of operation. Late IABP-related sequelae occurred in 10 patients, 9 of whom had had early vascular complications. The presence of vascular complications per se was not a significant independent factor among other risk factors for mortality, morbidity, or long-term survival. Conclusions. Careful clinical assessment of the aortofemoral vascular tree is a cornerstone of early diagnosis and early intervention and usually prevents limb loss. The significant decrease in major vascular complications that has occurred over the last 5 years can be explained by the increased use of catheters with smaller diameters. The timing of IABP insertion in relation to operation and the duration of IABP use were the only device-related risk factors identified for morbidity and survival.
Axelrod DA, Stanley JC et al: Risk for stroke after elective noncarotid vascular surgery. J Vasc Surg 39: 67-72, 2004. Introduction: Patients undergoing operations to treat peripheral vascular disease have systemic atherosclerosis and are at risk for stroke. However, the incidence and effect of cerebrovascular events on noncarotid vascular surgical outcomes are not well-defined. Methods: Patients undergoing common operations for vascular disease from 1997 to 2000 were examined with data from the Veterans Affairs (VA) National Surgery Quality Improvement Project and the VA patient treatment files. Operations studied included abdominal aortic aneurysmectomy (n = 2551), aortobifemoral bypass (n = 2616), lower extremity bypass (n = 6866), and major lower extremity amputation (n = 7442). The incidence of perioperative stroke was determined, and logistic regression analysis was used to identify independent risk factors for stroke. Logistic and linear regression analyses were used to quantify the effect of postoperative stroke on adjusted mortality and length of stay. Odds ratio (OR) and 95% confidence interval (CI) were defined. P <.05 was considered significant. Results: Stroke was uncommon after noncarotid vascular procedures, occurring in only 0.4% to 0.6% of patients. Independent risk factors for stroke include preoperative ventilation (OR, 11; 95% CI, 5.0-22.3; P <.001), previous stroke or transient ischemic attack (OR, 4.2; 95% CI, 2.7-6.4; P <.001), postoperative myocardial infarction (OR, 3.3; 95% CI, 1.3-8.7; P =.009), and need to return to the operating room (OR, 2.2; 95% CI, 1.4-3.5; P =.001). Factors that did not appear to be associated with stroke risk included procedure type, diabetes, renal failure, dialysis dependence, number of transfused units of blood, and hypertension. After controlling for other postoperative complications and comorbid conditions, postoperative stroke significantly increased the risk for perioperative mortality (OR, 6.3; 95% CI, 3.4-11.4; P <.001), with similar magnitude as postoperative myocardial infarction (OR, 6.3; 95% CI, 3.9-10.1; P < .001). Stroke was also associated with a 48% increase in overall length of stay. Conclusions: Stroke after noncarotid peripheral vascular surgery is uncommon, but results in markedly increased mortality and length of stay. Stroke risk is most strongly associated with previous stroke history and greater degree of illness. Patients with these associated conditions deserve particular attention to assessing and medically managing modifiable risk factors.
Ballard JL, Sparks SR, Taylor FC, Bergan JJ, Smith DC, Bunt TJ, Killeen JD: Complications of iliac artery stent deployment. J Vasc Surg 24(4):545-53, 1996; discussion 553-5. PURPOSE: This study was performed to determine the primary patency, foot salvage, and complication rates associated with iliac artery stent deployment. METHODS: From March 1992 to May 1995, 147 iliac artery stents were deployed in 98 limbs of 72 patients for disabling claudication or limb-threatening ischemia. Procedure-related and late (> 30 days) complications, as well as adjunctive maneuvers required to correct a complication, were tabulated. Stented iliac artery cumulative primary patency and foot salvage rates were calculated with life-table analysis. Factors that impacted early complications, late complications, foot salvage rates, and stented iliac artery primary patency rates were identified with stepwise logistic regression analysis. RESULTS: A procedure-related complication occurred in 19 (19.4%) limbs. Initial technical success, however, was achieved in all but three of 98 limbs (96.9%). Stented iliac artery cumulative primary patency rates were 87.6%, 61.9%, 55.3%, and foot salvage rates were 97.7%, 85.1%, 76.1%, at 12, 18, and 24 months, respectively. External iliac artery stent deployment, superficial femoral artery occlusion before treatment, and single-vessel tibial runoff before treatment negatively affected stented iliac artery cumulative primary patency rates. Stented iliac artery primary patency rates were not significantly affected by age, smoking, coronary artery disease, diabetes, hypercholesterolemia, hypertension, presenting symptom, early complication, number of stents deployed, type of stent deployed, or stent deployment for stenosis versus occlusion. CONCLUSIONS: Limb-threatening and life-threatening complications can be associated with iliac artery stent deployment. Stented iliac artery primary patency rates are affected by distal atherosclerotic occlusive disease and the position of the deployed stent within the iliac system. Stent reconstruction of severe iliac artery occlusive disease is feasible but should be thoughtfully selected. Comments: Angioplasty and stents do cause complications. Collateral flow develops with time in many patients and may be hastened with boot therapy (left photograph below). The plaque material, of course, is impacted into the vessel wall with the balloon procedure occasionally leaving the patient with a patent vessel that has lost its nutrient vessels to the adjacent tissue (second photograph); this patient was left with a painful thigh. Other patients in our case history section were referred for boot therapy after having suffered peripheral embolization after the placement of stents.
Barner HB, Kaiser GC and Willman VL: Blood flow in diabetic leg. Circulation 43:391, 1971. Reconstruction and repair of diabetic lesion should not be withheld on basis of arteriolar-capillary disease.
Bartlett FR, Gibbon GW and Wheelock FC: Aortic reconstruction for occlusive disease. Comparable results in diabetics. Arch Surg 121:1150-1153, 1986. 57 diabetic (68% for limb salvage) and 43 nondiabetics (47% for limb salvage). Both groups left hospital with open grafts but had 9% late graft occlusion. 33% diabetics dead at 4 years vs 16% for nondiabetics.
Becquemin J-P for the Etude de la Ticlopidine apres pontage femoro-poplite and the Association Universitaire de Recherche en Chirurgie: Effect of ticlopidine on the long-term patency of saphenous-vein bypass grafts in the legs. N Engl J Med 337:1726-31, 1997. Abstract results: After two years, 66.4% of patients were alive with a patent graft in the ticlopidine group, as compared with 51.2% in the placebo group (95% confidence interval for the difference between the two groups, 2.9 to 27.4%; P=0.02). The two-year cumulative patency rate was 82% in the ticlopidine group and 63% in the placebo group (P=0.002). There was no significant difference between the groups in overall mortality or major ischemic events. Comments: Perhaps, we should give our boot patents ticlopidine also. The authors note that ticlopidine, presumably by its inhibition of platelet aggregation, has been reported to be effective in increasing walking distance and decreasing need for bypass surgery in claudicators and in reducing death rate, myocardial infarction and stroke.
Berlauk JF, Abrams JH, Gilmour IJ et al: Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. A prospective, randomized clinical trial. Ann Surg 214: 289-299, 1991. Abstract: The hypothesis that optimizing hemodynamics using pulmonary artery (PA) catheter (preoperative 'tune-up') would improve outcome in patients undergoing limb-salvage arterial surgery was tested. Eighty-nine patients were randomized to preoperative tune-up either in the surgical intensive care unit (SICU) (group 1) or the preinduction room (group 2) or to control (group 3). The tune-up consisted of fluid loading, afterload reduction, and/or inotropic support to achieve predetermined endpoints. Patients with a PA catheter had significantly fewer adverse intraoperative events (p less than 0.05), less postoperative cardiac morbidity (p less than 0.05), and less early graft thrombosis (p less than 0.05) than the control group. The overall study mortality rate was 3.4%, with a mortality rate of 9.5% in the control group and 1.5% in the PA catheter groups. There were no differences in ICU length of stay (LOS), hospital LOS, or total hospital costs, although the percentage of cost from complications was higher in group 3 (p greater than 0.05). In this group of patients, preoperative cardiac assessment and optimization is associated with improved outcome.
Bjerre-Jepsen K, Faris I et al: Effect of therapy on 24-h subcutaneous blood flow in the leg in patients with severe ischemia. Eur J Nucl Med 9:413-5, 1984. The effect of vascular surgical reconstruction or Buerger's exercises upon average subcutaneous blood flow for a 24-h period was studied in 14 patients with severe leg ischemia due to occlusive arterial disease. Blood flow was estimated proximally in the calf and in the foot by a 133Xe washout technique. Seven patients underwent vascular surgery. Postoperatively subcutaneous blood flow increased in the calf and the foot in all patients except one in whom a decrease in blood flow in the foot was seen. In this case a decrease in systolic blood pressure occurred following the operation. Buerger's exercises did not alter subcutaneous blood flow either in the calf or in the foot in the seven patients studied. Buerger's exercises seem to be of no value for these patients. The measurement of blood flow in subcutaneous tissue over a period of 24 h seems to be a useful test of the effect of different treatments. Comments: While Buerger's exercises may not help patients with severe PVD, a rocking bed in providing untiring treatments and a tilt of the entire body has had some benefit historically both in patients with PVD and pulmonary insufficiency. See Arch Phys Med Rehabil 37(10): 637-42, 1956 and (Influence of an oscillating bed on cutaneous temperature and oxygen tension of ischemic toes) Circulation 17:277-83, 1958.
Blair JM, Gewertz BL, Moosa H, Lu CT, Zarins CK: Percutaneous transluminal angioplasty versus surgery for limb-threatening ischemia. J Vasc Surg 9:698-703. 1989. This retrospective study compared the results of percutaneous transluminal angioplasty (PTA) with those of infrainguinal bypass procedures in patients with critical arterial ischemia to determine which procedure had superior patency, limb salvage, and durability. The records of 54 patients who underwent 54 PTAs and 56 patients who underwent 63 infrainguinal bypasses (29 femoropopliteal and 34 femorodistal) from 1981 to 1987 were reviewed. In each patient PTA or bypass was the initial vascular procedure. Patients in both groups were comparable with respect to age, sex, and the presence of diabetes, hypertension, obesity, hypercholesterolemia, and smoking. Mean follow-up was 40 months (4 to 88 months) for the PTA group and 28 months (6 to 78 months) for the surgery group. Thirty-nine of the 54 patients (72%) were initially improved after PTA, whereas 15 patients (28%) showed no improvement. During follow-up, 20 initially successful PTAs reoccluded. Thirty-two of 54 patients (59%) underwent subsequent procedures, which included repeat PTA (10) and distal bypass (14). Patency determined by noninvasive Doppler studies was 18% at 2 years. Limb salvage, which included such secondary procedures, was 78%. Two-year patency for femoropopliteal bypasses was 68% with a limb salvage of 90%. Femorodistal bypasses had a 2-year patency of 47% and a limb salvage of 74%. No perioperative deaths occurred. Twenty-one of the 63 patients (33%) had subsequent procedures, which included thrombectomy (5) and bypass revision (9). In patients treated for limb-threatening ischemia the 2-year patency after femoropopliteal bypass (68%) or femorodistal bypass (47%) is significantly better than that from PTA (18%, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Bloom RJ and Stevick CA: Amputation level and distal bypass salvage of the limb. Surg Gynecol Obstet 166:1-5, 1988. From Stanford...59% salvage rate... failure of the graft did not predispose to a subsequent amputation.
Bode RH Jr, Lewis KP, Zarich SW, Pierce ET, Roberts M, Kowalchuk GJ, Satwicz PR, Gibbons GW, Hunter JA, Espanola CC: Cardiac outcome after peripheral vascular surgery. Comparison of general and regional anesthesia. Anesthesiology 84: 3-13, 1996. BACKGROUND: Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia, most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences. This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease. METHODS: Four hundred twenty-three patients, between 1988 and 1991, were randomly assigned to receive general (n = 138), epidural (n = 149), or spinal anesthesia (n = 136) for femoral to distal artery bypass surgery. All patients were monitored with radial artery and pulmonary artery catheters. Postoperatively, patients were in a monitored setting for 48-72 h and had daily electrocardiograms for 4-5 days and creatine phosphokinase/isoenzymes every 8 h x 3, then daily for 4 days. Cardiac outcomes recorded were myocardial infarction, angina, and congestive heart failure. RESULTS: Baseline clinical characteristics were not different between anesthetic groups. Overall, the patient population included 86% who were diabetic, 69% with hypertension, 36% with a history of a prior myocardial infarction, and 41% with a history of smoking. Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received. In the intention to treat analysis, incidences of cardiac event or death for general, spinal, and epidural groups were 16.7%, 21.3%, and 15.4%, respectively. The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was -1.6% (95% confidence interval -9.2%, 6.1%) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia. CONCLUSIONS: The choice of anesthesia, when delivered as described, does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery. Comments: The kind of anesthesia may not influence outcome, but the risks of the surgery and anesthesia remain impressive even in good hands: incidences of cardiac event or death for general, spinal, and epidural groups were 16.7%, 21.3%, and 15.4%, respectively.
Boucher CA, Brewster DC, Darling RC et al: Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery. N Engl J Med 312: 389-394, 1985. Abstract: To evaluate the severity of coronary artery disease in patients with severe peripheral vascular disease requiring operation, we performed preoperative dipyridamole-thallium imaging in 54 stable patients with suspected coronary artery disease. Of the 54 patients, 48 had peripheral vascular surgery as scheduled without coronary angiography, of whom 8 (17 per cent) had postoperative cardiac ischemic events. The occurrence of these eight cardiac events could not have been predicted preoperatively by any clinical factors but did correlate with the presence of thallium redistribution. Eight of 16 patients with thallium redistribution had cardiac events, whereas there were no such events in 32 patients whose thallium scan either was normal or showed only persistent defects (P less than 0.0001). Six other patients also had thallium redistribution but underwent coronary angiography before vascular surgery. All had severe multivessel coronary artery disease, and four underwent coronary bypass surgery followed by uncomplicated peripheral vascular surgery. These data suggest that patients without thallium redistribution are at a low risk for postoperative ischemic events and may proceed to have vascular surgery. Patients with redistribution have a high incidence of postoperative ischemic events and should be considered for preoperative coronary angiography and myocardial revascularization in an effort to avoid postoperative myocardial ischemia and to improve survival. Dipyridamole-thallium imaging is superior to clinical assessment and is safer and less expensive than coronary angiography for the determination of cardiac risk.
Bursi1 F, Babuin L, Barbieri1 A et al: Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation. European Heart Journal 26: 2448-2456, 2005. Aims The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn). Methods and results Consecutive vascular surgery candidates (n=391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI=2.60-10.43; P<0.0001) in group 1 and 2.58 (95% CI=1.27-4.38; P=0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR=4.73, 95% CI=2.92-7.65; P<0.0001) and at 30 days (adjusted HR=5.52, 95%CI=3.23-9.42; P<0.0001). Conclusion After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.
Collins TC, Souchek J, Beyth RJ: Benefits of antithrombotic therapy after infrainguinal bypass grafting: a meta-analysis. Am J Med 117: 93-9, 2004. PURPOSE: We performed a meta-analysis to ascertain the benefits of antithrombotic therapy for maintaining the patency of vascular grafts following lower extremity bypass operations. METHODS: We identified articles using MEDLINE and hand searches of relevant journals for randomized clinical trials that compared the use of antithrombotic therapy with control or placebo therapy. Random-effects (DerSimonian and Laird) analyses were used to determine the risk of graft occlusion following lower extremity bypass operations. We also assessed the odds of secondary outcomes, such as myocardial infarction, cerebrovascular accident, all-cause mortality, and bleeding. RESULTS: Sixteen articles met the inclusion criteria of a randomized trial of antithrombotic therapy for the patency of vascular grafts; six were excluded because the analyses involved repeat surgeries or lacked a control group. Of the 10 studies included in the final analysis, seven compared antiplatelet agents with placebo or control, and three compared anticoagulant agents with placebo or control. The 10 studies were homogeneous in spite of differing durations of follow-up. The odds of graft occlusion in the treated group was half that in the placebo or control group. The odds ratio was 0.46 (95% confidence interval [CI]: 0.32 to 0.66) for the 10 studies that reported outcomes at 12 months or longer, 0.50 (95% CI: 0.29 to 0.87) in the five studies with 12-month rates; and 0.58 (95% CI: 0.39 to 0.88) at 24 months. CONCLUSION: Antithrombotic therapy decreases the risk of graft occlusion after a vascular operation by about 50% at 12 months and is still protective at 24 months after the operation. Comments: A choice of the risk of anticoagulation therapy versus the risk of graft occlusion.
Crescenzia G, Bovea T, Pappalardoa F et al: Clinical significance of a new Q wave after cardiac surgery. Eur J Cardiothorac Surg 25: 1001-1005, 2004. Objective: The appearance of new Q waves on the electrocardiogram (ECG) after cardiac surgery has been traditionally considered a sign of major myocardial tissue damage. The aim of this study was to investigate the clinical significance of new Q waves appearing following cardiac surgery and to correlate them with the release of myocardial cell damage biomarkers. Methods: 206 consecutive patients undergoing cardiac surgery were prospectively evaluated. A 12 lead ECG was recorded and cardiac troponin I and creatinekinase subfraction MB assayed the day before surgery, on arrival at the intensive care Unit. 4 and 18 h postoperatively and every morning until the fifth postoperative day. Results: The incidence of new Q waves was 7.3%. Patients with isolated ECG findings had an uneventful postoperative course; on the contrary, when ECG changes were coupled with the release of myocardial necrosis biomarkers, patients had a complicated postoperative course. Conclusions: The association of a new Q wave and high levels of myocardial necrosis biomarkers is strongly associated with postoperative cardiac events. On the contrary, the isolated appearance of a new Q wave has no impact on the postoperative cardiac outcome. Comments: Patients undergoing angioplasty for coronary heart disease or peripheral vascular disease are frightened as are their families. Perhaps, because they need reassurance that they will do well or because the physician believes the occurence of a small heart defect due to the procedure is a necessary complication of the procedure and worth the price for having possibly avoided much larger heart damage, the occurrence of the procedure-related damage is commonly not brought to the attention of the patient or their family and may not be mentioned in the discharge summary or the discharge list of diagnoses.
De Luca G, Ernst N, van't Hof AW, Ottervanger JP, Hoorntje JC, Gosselink AT, Dambrink JH, de Boer MJ, Suryapranata H: Predictors and clinical implications of early reinfarction after primary angioplasty for ST-segment elevation myocardial infarction. Am Heart J 151:1256-9, 2006. BACKGROUND: Recurrent infarction after fibrinolytic therapy has been shown to be associated with increased mortality. The aim of this study was to analyze predictors and outcome of reinfarction in a consecutive series of patients undergoing primary angioplasty. METHODS: Our population is represented by a total of 1955 patients with ST-segment elevation myocardial infarction treated by primary angioplasty between 1997 to 2002. All clinical, angiographic, and follow-up data were prospectively collected. Early reinfarction was defined when two clinical criteria were satisfied within 30 days after the procedure: (1) recurrent ischemic symptoms for >15 minutes after resolution of symptoms from initial MI; (2) new ST-T-wave changes or new Q waves; (3) reelevation in creatine kinase (CK) or CK-MB to higher levels than normal (or by another 20% if already higher than normal). RESULTS: Early reinfarction was observed in 75 (3.8%) patients. At multivariate analysis, advanced Killip class (P = .002), poor preprocedural TIMI flow (P = .014), administration of IIb-IIIa inhibitors (P = .02), and diabetes (P = .038) were independent predictors of 30-day reinfarction. A total of 107 (5.6%) patients had died. Early reinfarction was associated with a significantly higher mortality (22.7% vs 4.9%, P < .001), even after adjustment for confounding factors (blood pressure, diabetes, Killip class, preprocedural TIMI flow, coronary stenting, multivessel disease, anterior infarct location, preprocedural stenosis, and administration of IIb-IIIa inhibitors) (HR 3.32, 95% CI 1.88-5.84, P < .0001). CONCLUSIONS: This study showed that, among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction, advanced Killip class at presentation, poor preprocedural TIMI flow, the use of IIb-IIIa inhibitors, and diabetes are independently associated with 30-day reinfarction. Early reinfarction is an independent predictor of 1-year mortality. Comments: A report of a natural early progression of disease, of a complication of therapy (impaction of plaque into small arteries by the angioplasty procedure or both?
de Virgilio C, Pak S et al: Cardiac assessment prior to vascular surgery: is dipyridamole-sestamibi necessary? Ann Vasc Surg 10:325-9, 1996. Dipyridamole-sestamibi (PMIBI) is recommended prior to vascular surgery in patients with > or = 1 Eagle criteria (Q waves, history of ventricular ectopy, diabetes, advanced age, and/or angina). To review our cardiac morbidity and mortality and the need for preoperative PMIBI, we reviewed 109 consecutive patients with a mean age of 59 years who underwent 145 elective major vascular procedures over a 1-year period. Seventy patients (with a mean of 0.8 Eagle criteria) underwent 92 vascular procedures without preoperative PMIBI and without coronary revascularization. Thirty-one patients (with a mean of 1.1 Eagle criteria) underwent 39 procedures without coronary revascularization following PMIBI, which showed reversible ischemia in seven and a fixed defect in 10; findings were normal in 14. Preoperative coronary bypass or angioplasty was limited to eight patients (14 procedures, mean of 1.6 Eagle criteria) who had unstable angina with (2 patients) or without (6 patients) acute myocardial infarction. There were four perioperative myocardial infarctions (2.8%), seven cardiac events overall (4.8%), and one cardiac death (0.7%). Three (43%) of the seven cardiac events occurred in patients with a normal scan or fixed defect on PMIBI imaging. In the absence of unstable angina, PMIBI had a sensitivity of only 25% and a specificity of 80% for cardiac events. We conclude that among patients without severe cardiac symptoms (1) PMIBI has a very limited ability to identify patients at risk for cardiac complications, and (2) preoperative PMIBI is neither necessary nor cost-effective.
Clark TW, Groffsky JL, Soulen MC: Predictors of long-term patency after femoropopliteal angioplasty: results from the STAR registry. J Vasc Interv Radiol 12(8):923-33, 2001. PURPOSE: To identify variables predictive of long-term patency after femoropopliteal angioplasty. MATERIALS AND METHODS: The primary patency of 219 limbs in 205 patients from a multicenter registry who underwent femoropopliteal angioplasty between January 1, 1992, and December 31, 1994, was prospectively monitored with a combination of angiography, noninvasive hemodynamic testing, and clinical outcome. Patient demographic, angiographic, and hemodynamic variables were examined alone and in combination to determine effect on long-term primary patency. Each limb was graded as Category 1-4 according to the American Heart Association (AHA) criteria for arterial lesions, and differences in outcome for each category were examined. Primary patency and intergroup analysis were determined with use of the Kaplan-Meier method and log-rank test, respectively. Cox proportional hazards models were used to calculate relative risks for predictive variables. RESULTS: Primary patency rates for all limbs (on an intent-to-treat basis) at 12, 24, and 36 months were 87% +/- 3%, 80% +/- 3%, and 69% +/- 5%, respectively. Primary patency at 48 and 60 months was 55% +/- 7%. Poor tibial runoff (single tibial vessel with 50%-99% stenosis or occlusion) was most predictive of occlusion (relative risk 8.5, P <.0001). The presence of diabetes or renal failure was associated with lower long-term patency (relative risk 5.5 and 4.0, P <.0001 and.0002, respectively). Long-term patency was higher with AHA Category 1 lesions (P =.006), and no significant difference in patency was observed between Category 2 and 3 lesions (P =.65). A multivariate Cox proportional hazards model showed only the stratified runoff score and the presence of diabetes to be significant determinants of long-term patency. CONCLUSION: Poor tibial runoff is most predictive of lower long-term patency rates. Diabetes is also independently associated with lower long-term patency rates. The criteria that distinguish Category 2 and 3 lesions do not predict differences in long-term patency, nor do they serve to identify lesions best treated with surgical bypass. This suggests that indications for femoral angioplasty can be extended to include longer and more complex Category 3 lesions.
DeFrang RD, Edwards JM, Moneta GL, Yeager RA, Taylor LM and Porter JM: Repeat leg bypass after multiple prior bypass failures. J Vasc Surg 19:268-77, 1994. From 1980 to 1992, 81 patients had 85 procedures having had 3 previous procedures in 72, 4 previous procedures in 6 and 5 previous procedures in 7 patients. Twenty percent had diabetes, 83% had a history of smoking and none had kidney failure or renal insufficiency. Fifteen percent of the patients screened after 1987 had a hypercoagulable state due to anticardiolipin antibodies and were largely later maintained on warfarin. Thirty percent of the repeat bypasses were revisions of grafts found to be failing by routine surveillance methods and 69% of the repeat grafts were replacements of thrombosed grafts. Three patients died within 30 days of surgery and 15 were dead at a men interval of 24 months. Ten limbs were amputated at a mean interval of 9.8 months. Mean follow-up after the most recent operation was 17 months. The primary patency rate at 4 years was 79.8% and the limb salvage rate at 4 years was 69.6%. The authors conclude that their results justify an aggressive policy of limb revascularization after multiple failed prior bypasses. Comments: Lots of surgery here... 360 bypass procedures (past and present) among 81 patients on one leg. In their introduction, the authors quote previous literature showing a 30-52% limb salvage rate in patients undergoing repeat operations. In our experience, the risk of amputation increases with the number of failed bypasses. These patients did well and were relatively young (average age 68). Most were smokers. How many stopped smoking?
Desgranges P, Kobeiter K, d'Audiffret A, Melliere D, Mathieu D, Becquemin JP. Acute occlusion of popliteal and/or tibial arteries: the value of percutaneous treatment. Eur J Vasc Endovasc Surg 20(2):138-45, 2000. OBJECTIVES: to describe early and mid-term results with a percutaneous therapeutic protocol including thromboaspiration, thrombolysis, and correction of the underlying lesion by PTA. METHODS: thirty-three consecutive selected patients with recent (<1 month) reversible acute ischaemia associated with popliteal and/or tibial occlusion were studied. The primary endpoints were technical success (defined as residual mural thrombus less than 20% of the lumen and the presence of at least one tibial artery on angiogram), patient survival and limb salvage at 1 and 12 months. Secondary endpoints included complications, primary, assisted primary and secondary patency determined by duplex scan at 1, 6 and 12 months. RESULTS: technical success was achieved in 27 patients (82%). Twenty patients were treated by thrombo- aspiration+/-thrombolysis only, and seven required additional PTA (26%). In six patients (18%), percutaneous techniques failed, and embolectomy was performed in two, bypass in one and major amputations in three (9%). For the entire series, the survival rate was 100% at 1 month and 94% at 1 year. The limb salvage rate was 91% at 1 month and 1 year. The cumulative primary patency, assisted primary patency and secondary patency rates were 81%, 81% and 86% respectively at 1 month and 66%, 72% and 77%, respectively, at 12 months. Early complications occurred in 10 patients (30%): five groin haematomas (15%), four compartment syndromes (12%) and one haemoglobinuria (3%). CONCLUSION: percutaneous techniques offer excellent early and mid-term results in selected patients presenting with acute ischaemia with popliteal and/or tibial arteries occlusion
Dorros G, Jaff MR, Dorros AM, Mathiak LM, He T: Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up. Circulation 104(17):2057-62, 2001. BACKGROUND: In a prospective, nonrandomized, consecutive series of tibioperoneal vessel angioplasty (TPVA), critical limb ischemia (CLI) patients' data were analyzed with regard to immediate and follow-up success. METHODS AND RESULTS: TPVA was successful in 270 of 284 critically ischemic limbs (95%), with 167 limbs (59%) requiring dilatation of 333 ipsilateral inflow obstructions to access and successfully dilate 486 of 529 (92%) tibioperoneal lesions. A clinical success (relief of rest pain or improvement of lower-extremity blood flow) was attained in 270 limbs at risk (95%). Clinical 5-year follow-up of 215 of 221 successful CLI patients (97%) with 266 successfully revascularized limbs revealed that bypass surgery occurred in 8% and significant amputations in 9% of limbs; 91% of the limbs were salvaged. The cohort's probability of survival was 56%: 58% for Fontaine class III and 33% for class IV patients. Class III compared with class IV patients had significantly (P<0.05) fewer surgical bypasses (3% versus 16%) and amputations: above-knee, 1% versus 4%; below-knee, 3% versus 12%; and transmetatarsal, <1% versus 21%. CONCLUSIONS: TPVA, often in combination with inflow lesions, is an effective primary treatment for critical limb ischemia. The poor cumulative survival reflects the existence of severe comorbidities, which could potentially be affected by aggressive and effective cardiovascular diagnostic and therapeutic strategies. Comments: Patients failing angioplasty are commonly referred for boot therapy and present in sufficient numbers to give us the impression that angioplasty and stenting below the knee is to be avoided. We are including this and other articles to show some are reporting favorable experience.
Eickhoff HJ, Hanson B, Lorentzen JE: The effect of arterial reconstruction on lower limb amputation rate. Acta Chir Scand 502:181-187, 1980. National computer shows no decrease in amputations in Denmark.
Eskelinen E, Lepantalo M: Role of infrainguinal angioplasty in the treatment of critical limb ischaemia. Scand J Surg 96: 11-6, 2007. OBJECTIVE: To review the published papers reporting on the use of infrainguinal angioplasty in the treatment of critical limb ischaemia (CLI). METHODS: A MEDLINE (1966-2005) and Cochrane library search for articles relating to the use of infrainguinal angioplasty in the treatment of CLI. RESULTS: Recent papers reporting on the results of infrainguinal angioplasty as treatment for CLI patients show excellent limb salvage rates regardless of the patency rates. The Cochrane Database of systematic reviews has accepted two prospective randomised trials comparing bypass operations and angioplasty among CLI patients. Pooling both trials showed no overall significant difference in amputation rates between the surgery and PTA groups. A multicentre, randomised controlled trial, the BASIL (Bypass versus Angioplasty in Severe Ischaemia of the Leg) trial showed that in the medium term (after six months), the outcomes after angioplasty or surgery among CLI patients did not differ significantly with respect to amputation-free survival, all-cause mortality and quality of life. CONCLUSIONS: Infrainguinal PTA is feasible in CLI patients. Data from the BASIL trial show the similar ability of bypass surgery and balloon angioplasty in preserving both life and limb in short term. These results are, however, not applicable for the majority of CLI patients as only 15% (70/456) of the patients with severe limb ischaemia were considered candidates for the trial. Comments: Italics added by CBC editor not authors of article.
Faglia E, Dalla Paola L, Clerici G et al: Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc 29:620-7, 2005. OBJECTIVE: To evaluate the effectiveness of peripheral angioplasty (PTA) as the first-choice revascularisation procedure in diabetic patients with critical limb ischemia (CLI). DESIGN: Prospective study. METHODS: PTA was employed as first choice revascularisation in a consecutive series of diabetic patients hospitalized for CLI between January 1999 and December 2003. RESULTS: PTA was successful performed in 993 patients. Seventeen (1.7%) major amputations were carried out. One death and 33 non-fatal complications were observed. Mean follow-up was 26+/-15 months. Clinical restenosis was observed in 87 patients. The 5 years primary patency was 88%, 95% CI 86-91%. During follow-up 119 (12.0%) patients died at a rate of 6.7% per year. CONCLUSIONS: PTA as the first choice revascularisation procedure is feasible, safe and effective for limb salvage in a high percentage of diabetic patients. Clinical restenosis was an infrequent event and PTA could successfully be repeated in most cases.Comments: For Dr. Faglia's view of hyperbaric oxygen see www.circulatorboot.com/literature/cellulit.html. This current report is large (993 patients) and limited to diabetics (rare for PTA studies), but uncontrolled. The degree of ischemia in their patients is uncertain. The study population had at least one missing or reduced pedal pulse, a TcPO2 under 50 mmHg on the dorsum of the foot and a duplex scan showing one or more stenoses >50% of vessel diameter. As found in our library on vascular tests, many people may heal with TcPO2's in the 20-50 range and over 40 is considered normal. The presence of one pedal pulse may adequately supply distal blood flow (as might a successful bypass). Success was defined essentially by the absence of above-the-ankle amputations.
Fine MJ, Kapoor W, Falanga V: Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology 38:769-84, 1987. Cholesterol crystal embolization (CCE) frequently presents with nonspecific manifestations that mimic other systemic diseases. The authors reviewed 221 cases of histologically proven CCE in the English literature to define the clinical, laboratory, and pathologic characteristics of this disorder. CCE affected predominantly elderly males (mean age sixty-six) with a frequent history of hypertension (61%), atherosclerotic cardiovascular disease (44%), renal failure (34%), and aortic aneurysms (25%) at presentation. At least one possible predisposing factor was present in 31% and included operative and radiological vascular procedures and the use of anticoagulants. Cutaneous findings (34%) and renal failure (50%) were two of the most common clinical findings throughout the course of CCE. The nonspecific signs and symptoms included: fever (7%), weight loss (7%), myalgias (4%), and headache (3%). Premortem diagnoses were established in 31% of patients most commonly by biopsy of the muscle, skin, and kidney. Mortality was high (81%) and was most commonly due to multifactorial, cardiac, and renal etiologies. The authors conclude that CCE should be strongly considered in elderly patients with atherosclerotic vascular disease who have the onset of renal insufficiency and cutaneous manifestations. CCE may be confirmed by a skin or muscle biopsy.
Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A: The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol 42:217-8, 2003. BACKGROUND: Cholesterol embolization syndrome is a systemic disease caused by distal showering of cholesterol crystals after angiography, major vessel surgery, or thrombolysis. METHODS: We prospectively evaluated a total of 1,786 consecutive patients 40 years of age and older, who underwent left-heart catheterization at 11 participating hospitals. The diagnosis of CES was made when patients had peripheral cutaneous involvement (livedo reticularis, blue toe syndrome, and digital gangrene) or renal dysfunction. RESULTS: Twenty-five patients (1.4%) were diagnosed as having CES. Twelve patients (48%) had cutaneous signs, and 16 patients (64%) had renal insufficiency. Eosinophil counts were significantly higher in CES patients than in non-CES patients before and after cardiac catheterization. The in-hospital mortality rate was 16.0% (4 patients), which was significantly higher than that without CES (0.5%, p < 0.01). All four patients with CES who died after cardiac catheterization had progressive renal dysfunction. The incidence of CES increased in patients with atherosclerotic disease, hypertension, a history of smoking, and the elevation of baseline plasma C-reactive protein (CRP) by univariate analysis. The femoral approach did not increase the incidence, suggesting a possibility that the ascending aorta may be a potential embolic source. As an independent predictor of CES, multivariate regression analysis identified only the elevation of pre-procedural CRP levels (odds ratio 4.6, P = 0.01). CONCLUSIONS: Cholesterol embolization syndrome is a relatively rare but serious complication after cardiac catheterization. Elevated plasma levels of pre-procedural CRP are associated with subsequent CES in patients who undergo vascular procedures. Comments: A 1.4% incidence of clinically apparent disease.
George SM Jr, Klamer TW, Lambert GE Jr: Value of continued efforts at limb salvage despite multiple graft failures. Ann Vasc Surg 8(4):332-6, 1994. Treatment of patients with limb-threatening ischemia after multiple failed bypasses remains difficult and controversial. Further revascularization procedures despite failure of the original procedure may be viewed as futile. The purpose of this report is to determine the efficacy of third or fourth revascularization procedures after the original and second procedures fail. Over a 10-year period from January 1, 1983, to December 31, 1992, 312 infrainguinal bypasses were performed on 271 consecutive patients for foot salvage. The overall limb salvage rate was 84%, and the operative mortality rate was 3.7% (10 patients). Sixteen patients (5.8%) had repeat infrainguinal bypasses performed after failure of two or more prior bypass procedures in the same leg. Twenty-three reconstructions were performed in these 16 patients. There were no operative deaths. One half of these patients had major amputations performed within the first year following their tertiary or fourth reconstructive procedure. Sixty-two percent of patients have survived longer than 3 years after their third or fourth procedure. One half of these patients have maintained graft patency and an excellent quality of life. Only 22% of the patients requiring amputation ambulated with a prosthesis, whereas all revascularized patients ambulated. Although this subset of patients is known to have an increased risk of repeated graft failure and limb loss, we believe continued efforts at limb salvage despite multiple previous graft failures is justified.
Glass H, Rowe VL, Hood DB, Yellin AE, Weaver FA: Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization. Am Surg.70(10):845-9, 2004. When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent (P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.
Goldman RJ, Brewley BI, Golden MA: Electrotherapy reoxygenates inframalleolar ischemic wounds on diabetic patients: a case series. Adv Skin Wound Care 15(3):112-20, 2002. OBJECTIVE: To retrospectively evaluate the ability of high voltage pulsed current (HVPC) to increase microcirculation in critically ischemic wounds (transcutaneous oxygen [TcPO(2)] less than 10 mm Hg) and, as a result, to improve wound healing. DESIGN AND METHODS: Clinical case series with successive adult diabetic subjects (3 men and 3 women) with nonsurgical ischemic malleolar or inframalleolar skin lesions, each subject serving as his or her own control. Wound area and TcPO(2) were measured periodically. Presence of distal arteriosclerosis was assessed on 5 patients by 2-dimensional, time-of-flight magnetic resonance angiography. End point was either complete wound closure or leg amputation. RESULTS: Maximum mean TcPO(2) was 2 +/- 2 mm Hg at the wound edge before the start of electrotherapy. After electrotherapy began, maximum TcPO(2) was 33 +/- 18 mm Hg (N=6; P<.05, Wilcoxon signed rank test). After treatment with HVPC, 4 patients' wounds healed and 2 patients underwent amputation. As expected, healed patients initially deteriorated after the start of treatment, but their wounds began healing when the perilesion TcPO(2) measurement exceeded 20 mm Hg. Thereafter, the wounds closed at a predictable rate. Complete closure occurred for patients who had a relatively low atherosclerotic burden. CONCLUSION: The results of this clinical case series suggest that electrotherapy can improve periwound microcirculation of ischemic inframalleolar skin lesions. Comments: TcPO(2) reflects indirectly the adequacy of the microcirculation. Very low values are seen also with cellulitis due to aerobic infections. Improved healing might be expected if electrotherapy helped sterilize the ulcers. It is hard to imagine how the application of electrodes around a distal ulcer might affect the blood flow through a critical stenosis in the mid-calf or thigh. In keeping with these thoughts is the observation of the authors that healing occurred in patients with a low atherosclerotic burden.
Golledge J, Ferguson K, Ellis M, Sabharwal T, Davies AH, Greenhalgh, Powell JT: Outcome of femoropopliteal angioplasty. Annals of Surgery 229(1): 146-53, 1999. Author's abstract: Objective: To assess prospectively the outcome of femoropopliteal angioplasty and investigate prognostic indicators of success. Background: Percutaneous transluminal angioplasty is commonly used to treat symptomatic femoropopliteal stenoses or occlusions, but the durability of the procedure is uncertain. Methods: Seventy-four consecutive patients treated by femoropopliteal angioplasty for intermittent claudication (43), rest pain (4), and tissue loss (27) were followed by assessment of symptoms, ankle-brachial pressure index (ABPI) to measure hemodynamic outcome, and duplex monitoring of velocity gradient at the angioplasty site to identify restenosis at 1 day and 3,6,9, and 12 months. Univariate comparisons, life table analysis, and backward stepwise regression were used to investigate factors predicting the symptomatic and hemodynamic outcome and restenosis. Results: Technical success was obtained in 67 patients (91%); failure occurred in 7 patients. At 1 year, a successful symptomatic outcome was achieved in 35 patients (51%), hemodynamic success was achieved in 41 patients (58%), and restenosis developed in 39%. ABPI at 24 hours after angioplasty was the most significant variable predicting a symptomatic outcome, hemodynamic outcome, and restenosis at 12 months. Life table analysis demonstrated that in 24% of patients with a 24-hour ABPI > or = 0.9, restenosis developed by 12 months, compared with 64% of patients with a 24-hour ABPI <0.9. Conclusion: Only half of the patients treated by femoropopliteal angioplasty had symptomatic improvement at 1 year, raising concern about the cost-benefit ratio of this procedure. Restoration of ABPI to >0.9 predicted a favorable outcome. Comments: For more on angioplasty success rates, see our section of claudication.
Gordon IL, Conroy RM, Arefi M, Tobis JM, Stemmer EA, Wilson SE: Three-year outcome of endovascular treatment of superficial femoral artery occlusion. Arch Surg 136(2):221-8, 2001. HYPOTHESIS: Patency after primary percutaneous transluminal angioplasty (PTA) and stenting of superficial femoral artery (SFA) occlusions is better than historical experience with PTA alone. DESIGN: Consecutive case series of primary PTA with stenting, and follow-up with duplex imaging every 6 months (mean +/- SD follow-up, 32 +/- 15 months). SETTING: Veterans Affairs medical center. PATIENTS AND METHODS: Patients were 57 previously untreated men with 71 limbs having chronic atherosclerotic SFA occlusion with suprageniculate reconstitution and patent tibial runoff. Critical ischemia (Society for Vascular Surgery [SVS] category, 4-6) was present in 7 (10%), the remainder had intermittent claudication only (SVS, 1-3). INTERVENTIONS: Guidewire recanalization followed by PTA, Wallstent deployment, and adjunctive thrombolysis as necessary; 19 limbs (27%) required thrombolysis to manage periprocedural thrombosis. MAIN OUTCOME MEASURES: Cumulative patency, limb salvage, and complications. RESULTS: Length (mean +/- SD) of occlusion was 14.4 +/- 9.9 cm. Length of stented artery was 24.3 +/- 11.1 cm. Ankle brachial index increased from 0.59 +/- 0.14 to 0.86 +/- 0.16 (P<.001) after stenting. One- and 3-year patencies were as follows: primary, 54.6% +/- 6.3% and 29.9% +/- 6.6%; assisted primary, 72.3% +/- 5.6% and 59.0% +/- 6.8%; and secondary, 81.6% +/- 4.8% and 68.3% +/- 6.5%. Three-year secondary patency when periprocedural thrombolysis was required was 35.7% +/- 12.5% compared with 70.6% +/- 7.4% for limbs not requiring periprocedural thrombolysis (P=.02); the differences in occlusion length and severity of ischemia were not significant between these 2 groups. Limbs undergoing adjunctive PTA during angiography 6 to 12 months after initial stenting had 63.0% +/- 13.3% patency at 3 years compared with 100% patency in limbs not requiring PTA at 6 to 12 months angiography (P=.046). Periprocedural mortality and morbidity were 2.8% and 15.5%, respectively. Three of the 7 limbs with critical ischemia underwent amputation during follow-up compared with 2 (3%) of 64 limbs with functional ischemia (chi(2) test, P<.006). A mean of 1.8 endovascular interventions per limb were performed. CONCLUSIONS: Percutaneous transluminal angioplasty and stenting yielded higher patency rates than historical controls undergoing PTA alone. When periprocedural thrombolysis is required, subsequent patency appears to be significantly worse. Poor results after PTA and stenting of limbs with critical ischemia and the need for additional endovascular therapy limit the technique's utility.
Grüntzig A, Schneider HJ: [The percutaneous dilatation of chronic coronary stenoses--experiments and morphology] [Article in German] Schweiz Med Wochenschr 107:1588, 1977. Since 1971, percutaneous transluminal angioplasty of peripheral arteries has been performed in 225 patients. There was an overall patency rate of 70-80% after 2 years. Our technique was then adapted and modified to perform coronary dilatation. This was performed successfully in 8 dogs in which selective coronary artery stenosis war induced by silk ligature and secondary inflammatory changes. The technique was then applied to the coronary lesions in postmortal humans and tested in the operating room during A-C bypass to evaluate vessel patency, peripheral debris etc.
Haider SN, Kavanagh EG et al: Two-year outcome with preferential use of infrainguinal angioplasty for critical ischemia. J Vasc Surg 43:504-12, 2006. OBJECTIVE: Infrainguinal angioplasty provides a minimally invasive alternative to bypass surgery in patients with critical ischemia. This study aimed to determine the 2-year patency, limb salvage, and survival rates in patients who underwent infrainguinal angioplasty in a unit where angioplasty is used preferentially whenever possible for critical ischemia. METHODS: A total of 333 consecutive patients who presented with rest pain, tissue loss, or both and who underwent an infrainguinal intervention in the 4-year period between January 1998 and January 2002 were divided into femoropopliteal and femorodistal groups. The TransAtlantic Inter-Society Consensus angiogram scoring system was used to classify the lesions. Angioplasty was the preferred procedure in all patients for whom a stump or portion of a superficial femoral artery was patent. Exclusion criteria included the concomitant or sequential treatment of iliac lesions. Patients were followed up after surgery with ankle-brachial indices and duplex ultrasonography. RESULTS: A total of 180 patients underwent 198 angioplasties. Primary cumulative patency, limb salvage, and survival for femoropopliteal angioplasty (n = 166) at 2 years were 75%, 90%, and 88%, respectively, and 60%, 76%, and 82% for infrapopliteal angioplasty (n = 32). At 30 days, mortality was 2.7%, and the complication rate was 8.3%. There was a restenosis rate (>50%) of 68% and 65% at 2 years for the femoropopliteal and infrapopliteal angioplasty groups, respectively. Seven patients required repeat angioplasty of the same site, 30 underwent subsequent bypass, and 16 of 43 occluded limbs were amputated. A total of 153 comparative control patients underwent 162 bypass procedures during the same period. Primary cumulative patency, limb salvage, and survival for femoropopliteal bypass (n = 80) at 2 years were 69%, 87%, and 76%, respectively, and were 53%, 57%, and 64% for infrapopliteal bypass (n = 82). The 30-day mortality for bypass was 5.2%, the complication rate was 35%, and 31 limbs were amputated. CONCLUSIONS: The results of this study on the intermediate-term outcome of angioplasty suggest that angioplasty, when used preferentially for critical ischemia, in anatomically suitable patients provides very acceptable limb salvage and survival despite a relatively high restenosis rate.
Hanna GP, Fujise K, Kjellgren O, Felf S, Fife C, Schroth G, Clanton T, Anderson V, Smalling RW: Infrapopliteal transcatheter interventions for limb salvage in diabetic patients: Importance of aggressive interventional approach and role of transcutaneous oximetry. J Am Coll Cardiol 30: 664-9, 1997. Abstract: Methods: Percutaneous interventions were performed were performed in 29 consecutive diabetic patients in need of limb salvage. Technical success was defined as <20% residual vessel stenosis. Clinical success was defined as avoidance of amputation and achievement of wound healing. At hospital discharge, patients were treated with Coumadin and aspirin. Ankle-brachial index (ABI) and TcO2 measurements were obtained before and after the intervention. Results: After 12-month follow-up, six patients had persistent wounds, whereas 23 experienced wound healing. Forty of the 50 infrapopliteal arteries successfully dilated were occluded, with a mean lesion length of 18.0 ± 3.5 cm. After the procedure, TcO2 improved from 27.82 ± 9.97 mm Hg (95% confidence interval [CI] 23.95 to 31.69) to 54.5 ± 14.73 mm Hg (95% CI 48.79 to 60.21, p>< 0.0001), whereas the ABI did not (p>0.2). Tc O2 predicted procedural and clinical success (p < 0.0182). Conclusions: Infrapopliteal transcatheter interventions in diabetic patients may salvage the majority of limbs doomed to amputation. Although TcO2 measurements are valuable in predicting wound healing and success after interventions, ABI measurements are not. Comments: This paper described much greater success than we have experienced with angioplasties below the knee, which have usually failed within a few weeks time. One is not sure why these legs were considered "doomed". The average baseline TcPO2 was not so low that healing was out of the question (see Vascular testing section of our library). Again, 65% of their patients apparently had hyperbaric therapy after the procedure. Finally, we are not told how much effort had been expended in trying to heal these patients before they were offered angioplasty.
Harmon JW and Hoar CS Jr: Cloth femoral popliteal bypass grafts in 29 diabetics. Arch Surg 106:282, 1973. Major amputation common if graft closes.
Hertzer NR, Beven EG, Young JR et al: Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 199: 223-233, 1984. Abstract: In an attempt to reduce early and late mortality caused by myocardial infarction, coronary angiography was performed in 1000 patients (mean age, 64 years) under consideration for elective peripheral vascular reconstruction since 1978. Those found to have severe, surgically correctable coronary artery disease (CAD) were advised to undergo myocardial revascularization (CABG), usually preceding other vascular procedures. The primary vascular diagnosis was abdominal aortic aneurysm (AAA) in 263 patients (mean age, 67 years), cerebrovascular disease (CVD) in 295 (mean age, 64 years), and lower extremity ischemia (ASO) in 381 (mean age, 61 years). Severe correctable CAD was identified in 25% of the entire series (AAA, 31%; CVD, 26%; and ASO, 21%). Surgical CAD was documented in 34% of patients suspected to have CAD by clinical criteria (AAA, 44%; CVD, 33%; and ASO, 30%) and in 14% of those without previous indications of CAD (AAA, 18%; CVD, 17%; and ASO, 8%). Cardiac procedures (216 CABG) were performed in 226 patients (AAA, 30%; CVD, 22%; and ASO, 19%), with 12 (5.3%) postoperative deaths. A total of 796 patients underwent 1066 peripheral vascular operations with an early mortality of 2.0% (AAA, 3.4%; ASO, 1.9%; and CVD, 0.3%), but only one death (0.8%) occurred in the group of 130 patients having preliminary CABG. The overall operative mortality for 1292 cardiac and peripheral vascular procedures was 2.6%.
Humphrey LL, Ballard DJ, Butters MA, Palumbo PJ and Hallett JW: The epidemiology of lower extremity amputation in diabetes: a population based study in Rochester, Minnesota. Diabetes 1989, 38 Suppl 2:33A. Between 1945 and 1984 the incidence rate of amputation increased for both male and female diabetics. Each 10 year increase in age at the time of diagnosis is the most significant risk factor for amputation. Despite advances in therapy, amputation will continue to be an important public health problem particularly as the population ages.
Jämsén T, Manninen H, Tulla H and Matsi P: The Final Outcome of Primary Infrainguinal Percutaneous Transluminal Angioplasty in 100 Consecutive Patients with Chronic Critical Limb Ischemia. Journal of Vascular and Interventional Radiology 13:455-463, 2002. PURPOSE: This study was performed to determine final outcomes in patients treated with infrainguinal percutaneous transluminal angioplasty (PTA) for chronic critical limb ischemia (CLI). MATERIALS AND METHODS: The study population consisted of 100 consecutive patients (mean age, 72 y; range, 38–90 y; 40 men and 60 women) with 116 treated limbs. CLI was defined as rest pain or ischemic tissue defect combined with an ankle systolic pressure <= 50 mm Hg. Indication for treatment was rest pain in 23 limbs (20%), ischemic ulcer in 50 (43%), and gangrene in 43 (37%). All patients were followed until they had met the study endpoints: major amputation or death. The mean follow-up period was 38 months (1–119 mo). Limb salvage, survival, and life with limb rates were determined along with their determinants. RESULTS: On average, 1.9 invasive procedures were required during the lifespan of a critically ischemic limb, including primary PTA and 32 repeat PTA procedures, 11 surgical revascularizations, and 51 amputations. The major amputation rate was 32% (n = 37). Limb salvage for endovascular treatments at 3, 5, and 8 years was 65%, 60%, and 60%, respectively (SE of estimate [SEE] <= 0.06), and the corresponding life with limb rates were 29%, 18%, and 6% (SEE <= 0.05). A greater number of diseased vessels in the treated limb was associated with poorer limb salvage (P = .004). Survival rates were 41%, 26%, and 14% (SEE <= 0.05) at 3, 5, and 10 years. The 10-year survival rate was markedly poorer than that in the age- and sex-matched control population. Coronary artery disease (P = .001) and poor peripheral runoff (P = .02) were associated with decreased survival. CONCLUSIONS: Infrainguinal PTA in patients with CLI results in acceptable limb salvage with a low number of additional revascularization treatments, but patient survival is poor. Comments: Not really a randomized controlled study.... All patients suitable for PTA got it.... Compared with patients not suitable who were bypassed.
Jonson BL, Glickman MH, Bandyk DF and Esses GE: Failure of foot salvage in patients with end-stage renal disease after surgical revascularization. J Vasc Surg 22:280-5, 1995. PURPOSE: This report ascertained factors responsible for for failure of foot salvage in patients with end-stage renal disease (ESRD) after undergoing infrainguinal bypass for critical ischemia. METHODS: A retrospective review of 69 distal arterial reconstructions performed in 53 patients with ESRD (hemodialysis [n = 37], kidney transplantation [n = 10], peritoneal dialysis [n = 6]) for foot gangrene (n = 28), nonhealing ulcer (n = 25), or ischemic rest pain (n = 16) was conducted. Endpoints of surgical morbidity, limb loss, and graft patency were correlated with extent of preoperative tissue loss and presence of diabetes mellitus. RESULTS: The 30-day operative mortality rate was 10%, and the patient survival rate at 2 years was 38%. The primary graft patency rate was 96% at 30 days, 72% at 1 year, and 68% at 2 years. Eleven of 22 foot amputations performed during the mean follow-up period of 14 months (range 3 to 96 months) occurred within 2 months of revascularization. Mechanisms responsible for limb loss included graft failure (n = 9), foot ischemia despite a patent bypass (n = 8), and uncontrolled infection (n = 5). Overall, 59% of amputations were performed in limbs with a patent bypass to popliteal or tibial arteries. Healing of forefoot amputations was prolonged, but all limb loss beyond 9 months of revascularization was due to graft failure. The limb salvage rate at 1 year decreased (p = 0.13) from 74% to 51% in patients admitted with gangrene. Only two of seven patients admitted with forefoot gangrene experienced foot salvage. CONCLUSION: Failure of foot salvage in patients with ESRD and critical ischemia was due to wound healing problems rather than graft thrombosis. Earlier referral for revascularization, before development of extensive tissue ischemia and infection, is recommended. Primary amputation should be considered in patients admitted with forefoot gangrene, particularly if it is complicated by infection. Comments: Patients with ESRD have long been known to have an increased risk for foot gangrene. Besides generalized ASCVD, their hemodialysis itself poses significant risk. Large fluid volumes may be dialyzed from the body causing hypotension and faintness. The dialysis chair is commonly then flattened and the feet raised potentially leaving the feet without arterial flow for minutes to hours. In a more recent study, Boufi et al (Foot Gangrene in Patients with End-Stage Renal Disease: A Case Control Study. Angiology 57:355-61, 2006) compared patients with foot gangrene and ESR to controls with foot gangrene and no ESR; the ESR patients had a higher mortality 68.7% vs 12.5% and major amputation rate 31% vs 8% along with more extensive arterial calcification and a higher calcium-phosphorus product. The latter raises the problem of calciphylaxis which has in ESR patients been associated not only with foot gangrene but gangrene of other tissues such as the penis (Guvel S et al: Penile Necrosis. J of Andrology 25, 2004).
Johnson KW et al: 5-year results of a prospective study of percutaneous transluminal angioplasty. Ann Surg 26:403-413, 1987. 984 consecutive PTA's...initial success rate 88.6% and at five years 48.2%. Success more likely if done for claudication vs salvage, if site common iliac vs other, if a stenotic lesion vs occlusion, and if good runoff - Comment: No controls and question of desirability of a procedure for claudication.
Kalbaugh CA, Taylor SM, Blackhurst DW et al: One-year prospective quality-of-life outcomes in patients treated with angioplasty for symptomatic peripheral arterial disease. J Vasc Surg 44(2): 296-302, 2006. BACKGROUND: Despite lower reported patency rates than open bypass, percutaneous transluminal angioplasty (PTA) may result in symptom relief, limb salvage, maintenance of ambulation and independent living, and overall improved quality of life. The goal of this study was to prospectively assess quality of life and functional outcomes after angioplasty and stenting in patients with chronic leg ischemia. METHODS: From August to December 2002, 84 patients with 118 chronically ischemic limbs underwent PTA with or without stenting as part of an ongoing prospective project performed to examine management of symptomatic peripheral arterial disease. All patients completed a preprocedure health questionnaire (Short Form 36) to provide adequate baseline data. Each patient was followed up every 3 months after treatment for 1 year to determine traditional outcomes of arterial patency, limb salvage, survival and amputation-free survival, and functional outcomes assessed according to improvement in quality of life, maintenance of ambulatory status, and maintenance of independent living status. The entire cohort was analyzed, as were subgroups of patients with lifestyle-limiting claudication and those with critical limb ischemia. Outcomes were analyzed by using Kaplan-Meier life-table analysis, the log-rank test for survival curves, and the one-sample t test. A Cox proportional hazard model was used to determine whether presentation and level of disease were independent predictors of outcome. RESULTS: Of the 84 patients, 54 (64.3%) were treated for claudication (34 aortoiliac occlusive disease and 20 infrainguinal disease), and 30 (35.7%) were treated for critical limb ischemia (11 aortoiliac occlusive disease and 19 infrainguinal disease). One-year results for the 54 patients with claudication were as follows: primary patency, 78.5%; limb salvage, 100%; amputation-free survival, 96.3%; survival, 96.3%; maintenance of ambulation status, 100%; and maintenance of independence, 100%. There was statistical improvement in all physical function categories, including physical function (29.4 +/- 8.9 vs 37.1 +/- 11.3; P < .0001), role-physical (32.5 +/- 11.3 vs 39.5 +/- 13.0; P = .0001), bodily pain (35.8 +/- 8.5 vs 42.9 +/- 10.9; P < .0001), and aggregate physical scoring (31.1 +/- 9.7 vs 38.1 +/- 11.5; P < .0001). One-year results for the 30 patients with critical limb ischemia were as follows: primary patency, 35.2%; limb salvage, 77.2%; amputation-free survival, 50.0%; survival, 60.0%; maintenance of ambulation status, 75.8%; and maintenance of independence, 92.8%. There was statistical improvement in bodily pain resolution (35.3 +/- 12.0 vs 46.6 +/- 12.0; P = .0009). Cox models with hazard ratios (HRs) revealed that presentation was a significant predictor for outcomes of primary patency (HR, 4.2; P= .0002), secondary patency (HR, 6.0; P < .0001), limb salvage (HR, 20.2; P = .0047), survival (HR, 10.9; P = .0002), and amputation-free survival (HR, 11.2; P < .0001). Conversely, the level of disease was predictive of outcome only for primary patency (HR, 1.8; P = .00289). CONCLUSIONS: Despite inferior reconstruction patency rates when compared with the historical results of open bypass, PTA provides excellent functional outcomes with good patient satisfaction, especially for treating claudication. These findings support a more liberal use of PTA intervention for patients with vasculogenic claudication. Comments: No control group. See Albers et al above.
Karnabatidis D, Katsanos K, Kagadis GC, et al: Distal embolism during percutaneous revascularization of infra-aortic arterial occlusive disease: an underestimated phenomenon. J Endovasc Ther.13:269-80, 2006.PURPOSE: To investigate distal embolism during endovascular procedures of the infra-aortic arteries by utilizing a commercial filter basket and unveil any correlation between the baseline clinical and procedural variables and the histopathological findings of the collected particles. METHODS: In a prospective study, 48 patients (37 men; mean age 70.8+/-7.8 years, range 50- 83) underwent endoluminal therapy of infra-aortic lesions (stenosis >75% or occlusion; mean lesion length 52.2+/-38.0 mm) with standard endovascular procedures. A nitinol filter basket (n=50) was employed for distal protection. The collected particles were histopathologically analyzed. The harvested specimens were quantified after digital image post processing. RESULTS: Procedural success of filter-protected revascularization was 93.8%. Three failures included 1 vasospasm, 1 distal embolus, and 1 side-branch occlusion. The total area of retrieved particles per basket was 2.76+/-6.49 mm(2) (range 0.0-40.3). Particles with a major axis >1 and >3 mm were detected in 29 (58.0%) and 6 (12.0%), respectively, of the examined filters. Collected particles consisted primarily of platelets and fibrin conglomerates, trapped erythrocytes, inflammatory cells, and extracellular matrix. Increased lesion length, increased reference vessel diameter, acute thromboses, and total occlusions were positively correlated with higher amounts of captured particles (p<0.05). Multivariate analysis incriminated declotting procedures as the only independent predictor of increased embolic burden (p<0.05). CONCLUSION: The embolism phenomenon during infra-aortic interventions is frequent and underestimated. The liberated particles consisted primarily of atheromatous plaque elements and thrombus. The reported data might support the application of a protective filter basket in selected subsets of lesions with a riskier embolic profile and whenever declotting procedures are performed.
Khan AM, Jacobs S: Trash feet after coronary angiography. Heart 89: e17, 2003. Cholesterol crystal embolisation is a frequently underdiagnosed condition. While coronary catheterisation is safe and commonly performed, the reported patient developed very painful trash feet after undergoing this routine procedure. Ulceration and gangrene occurred after catheter manipulation during cardiac angiography, which caused occlusion of the small arteries in his feet. The triad of pain, livedo reticularis, and intact peripheral pulses is pathognomonic for cholesterol embolisation. The prognosis depends on the extent of the systemic disease and a high rate of mortality (75-80%) is observed. Prognosis is poor and the treatment is only supportive. It is suggested that while cardiac catheterisation is largely safe and a very commonly performed procedure, it can still lead to complications with serious side effects and can even prove fatal.
Keen RR, McCarthy WJ, Shireman PK et al: Surgical management of atheroembolization. J Vasc Surg 21:773-781, 1995. The atheroembolic source is the aorta or iliac arteries in 2/3 of patients who underwent operation. CAT scan useful diagnostic techniques. Natural history includes 80% recurrence rate of emboli and 60% incidence of tissue loss. Precipitation events: use of warfarin (21), arteriography (17), percutaneous transluminal arteriography (5), trauma (5), and laparotomy (3 patients).
Kirwin JD, Ascer E, Gennaro M, Mohan C et al: Silent myocardial ischemia is not predictive of myocardial infarction in peripheral vascular surgery patients. Ann Vasc Surg 7:27-32, 1993. Continuous ambulatory ECG (CAECG) monitoring has been advocated as an effective low-cost preoperative method for detecting silent myocardial ischemia in patients undergoing peripheral vascular surgery. In addition, silent ischemic events are associated with an increased incidence of postoperative myocardial infarctions. Ninety-six patients (mean age 73 years) admitted for elective aortic (24) or infrainguinal (72) operations over a 2-year period underwent 24-hour two- or three-lead CAECG monitoring. Results were reviewed by a single cardiologist blinded to the study. The criterion for ischemia was ST segment depressions of 1 mm or greater for 40 seconds or more 60 msec after the J point. Postoperative myocardial infarction was determined by ECG changes and/or elevated serum creatinine phosphokinase with positive MB isoenzymes. Risk factors included hypertension (71%), history of coronary artery disease (66%), smoking (61%), and diabetes mellitus (47%). Nine out of 96 patients (9.4%) had a positive CAECG test for silent myocardial ischemia. Only one patient (11.1%) developed postoperative myocardial infarction and there were no deaths in this group. The incidence of postoperative myocardial infarction in the nonischemic group was 16.1% (14/87). However, the mortality in this group was 6.9% (6/87). New and malignant arrhythmias requiring preoperative medical intervention were observed in seven patients (7.4%): two cases of ventricular tachycardia and five cases of atrial flutter/fibrillation. Contrary to previous reports, CAECG monitoring for silent ischemia was not a significant predictor of postoperative myocardial infarction or mortality in our patient population. However, we continue to recommend the preoperative use of CAECG monitoring as a diagnostic tool for unsuspected malignant arrhythmias.
Krupski WC, Nehler NR, Whitehill TA, Lawson RC, Strecker PK, Hiatt WR: Negative impact of cardiac evaluation before vascular surgery. Vascular Medicine 5:3-9, 2000. The optimal preoperative evaluation of cardiac risk in patients with peripheral vascular disease is controversial. In developing a paradigm for preoperative cardiac workup, potential adverse effects of evaluation and cardiac intervention must be considered. This study analyzed the deleterious outcomes of extensive, comprehensive cardiac evaluation and intervention before planned vascular surgery in patients treated at the Denver Department of Veterans Affairs Medical Center. Over a 12-month period between 1994 and 1995, 161 patients were scheduled to undergo major vascular operations; 153 patients came to operation. The decision to pursue a cardiac evaluation was variously made by a combination of surgeons, cardiologists, and anesthesiologists. No defined protocol was followed. Cardiac history, chest X-rays and ECGs were obtained for all patients. Extendedcardiac evaluation included these studies plus special tests, including echocardiography (echo), radionuclide ventriculography (RNVG), dipyridamole thallium scintigraphy (DTS), and cardiac catheterization (CC). Extended cardiac evaluations were undertaken in 42 patients. Complications related to percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) were also recorded. Cardiac mortality and morbidity after vascular interventions were itemized in all 153 patients. Forty-two male patients, aged 68 6 9 years, underwent extended cardiac evaluations before planned vascular operations. The median elapsed time for cardiac workup was 14 days (mean 30 6 59 days). The median and mean times from cardiac workup to vascular surgery were 25 days and 76 6 142 days, respectively. Eighteen (43%) patients had echo or RNVG; 22 (52%) patients had DTS; 27 (64%) had CC; 9 (21%) had PTCA; 7 (17%) had CABG. Sixteen (38%) patients had untoward events related to cardiac evaluation. Eight patients (19%: one with cerebrovascular disease, and seven with aortic aneurysms) refused vascular surgery after extended cardiac workup. Complications attributable to CC, PTCA, and CABG included prosthetic graft infection, pseudoaneurysms (two), sternal wound infections (two), renal failure and brain anoxia. Two patients with severe limb ischemia who were candidates for revascularization ultimately required amputations because of delay due to cardiac evaluations. Extensive cardiac evaluation prior to vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates must be considered before ordering special studies.
Kudo T, Chandra FA, Ahn SS: The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience. J Vasc Surg 41:423-35, 2005. OBJECTIVE: To determine the efficacy, safety, and long-term results, including continued clinical improvement and limb salvage, of percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). METHODS: From August 1993 to March 2004, 138 limbs in 111 patients with CLI (rest pain in 62 [45%] and ulcer/gangrene in 76 [55%]) were treated by PTA. In iliac lesions, stents were placed selectively for primary PTA failure: residual stenosis (>30%) or pressure gradient (>5 mm Hg). Stent placement was limited in infrainguinal lesions. The most distal affected arteries treated with angioplasty were the iliac artery in 45 limbs (33%; iliac group), the femoropopliteal artery in 41 limbs (30%; FP group), and tibial arteries in 52 limbs (37%; BK group). All analysis was performed according to an intent-to-treat basis. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed to evaluate initial success, and late follow-up status was evaluated with the Kaplan-Meier method. Patency was evaluated by using ultrasound scanning and ankle-brachial pressure index measurement. RESULTS: There was one (0.9%) perioperative death. Twenty stents were placed selectively in 14 iliac arteries. Mean follow-up was 14.7 months (range, 1-75 months). Overall, initial technical and clinical success rates were 96.4% and 92.8%, respectively. The cumulative primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates +/- SE at 5 years were 31.4% +/- 10.4%, 75.5% +/- 5.7%, 79.6% +/- 5.5%, 36.1% +/- 10.0%, and 89.1% +/- 4.0%, respectively. In each subgroup, the primary, assisted primary, and secondary patency; continued clinical improvement; and limb salvage rates at 3 years were 51.6%, 94.7%, 97.8%, 65.1%, and 95.0%, respectively, in the iliac group; 49.4%, 72.2%, 76.4%, 57.4%, and 92.7%, respectively, in the FP group; and 23.5%, 41.8%, 46.1%, 51.1%, and 77.3%, respectively, in the BK group. Of the 12 predictable variables, hypertension, multiple segment lesions, more distal lesions, and TransAtlantic Inter-Society Consensus classification type D were significant independent risk factors for the outcomes ( P < .05; univariate log-rank test and Cox regression multivariate analysis). CONCLUSIONS: PTA is a feasible, safe, and effective procedure for the treatment of CLI. The high limb salvage rate is attributed to the high assisted primary and secondary patency rates despite the low primary patency rate. Angioplasty can be the primary choice for the treatment of CLI due to iliac and infrainguinal arterial occlusive disease. Comments: An impressive "observational" study. For those who require studies to be "controlled" and "prospective" to be considered evidence of efficacy, we might ask them how they would have accomplished the feat. See Hobbs and Bradbury in our Claudication library. Kudo et al report on more data generated by a single surgeon (J Vasc Surg 44:304-13, 2006) again supporting the use of PTA in treating CLI when possible. An increase in clinical success was gained at the expense of an increase in follow-up procedures.
Laird J, Jaff MR, Biamino G, McNamara T, Scheinert D, Zetterlund P, Moen E, Joye JD: Cryoplasty for the treatment of femoropopliteal arterial disease: results of a prospective, multicenter registry. J Vasc Interv Radiol 16:1051-4, 2005. PURPOSE: Despite suboptimal results (italics added by website editor), angioplasty of femoropopliteal arterial lesions has been a mainstay of endovascular therapy for many years. The recent introduction of cryoplasty marks a potential advance in the ability to effectively treat peripheral arterial atherosclerotic stenoses. This article presents the results of a prospective, multicenter trial that evaluated the efficacy of cryoplasty for femoropopliteal disease. MATERIALS AND METHODS: One hundred two patients with claudication and lesions of the superficial femoral and popliteal arteries of no greater than 10 cm were studied. All patients were treated with a primary strategy of stand-alone cryoplasty with use of the PolarCath cryoplasty system. The primary endpoints of the study were acute technical success and clinical patency at 9 months. Technical success was defined as the ability to achieve residual angiographic stenosis no greater than 30% and residual stenosis less than 50% by duplex ultrasound (US) imaging. Clinical patency was defined as freedom from target lesion revascularization within 9 months. Primary patency was defined by a duplex US systolic velocity ratio no greater than 2.0. RESULTS: A total of 102 patients were enrolled at 16 centers. Of those treated, 31% had diabetes and 31% were active cigarette smokers. The majority of the lesions were confined to the superficial femoral artery (84.3%) and 14.7% presented with total occlusions. The mean vessel diameter treated was 5.5 mm +/- 0.5, the mean stenosis diameter was 87% +/- 10%, and the mean lesion length was 4.7 cm +/- 2.6. The technical success rate was 85.3% with a mean residual stenosis after cryoplasty of 11.2% +/- 11.2% (P < .05 vs baseline). Clinical patency in this group was 82.2%, as only 16 patients required target lesion revascularization during the 9-month surveillance period. Primary patency determined by duplex US was 70.1%. CONCLUSIONS: Cryoplasty demonstrated a high degree of acute angiographic success and a low frequency of target lesion revascularization. The patency rate observed compares favorably to that previously documented with conventional angioplasty.
Landesberg G, Mosseri M, Zahger D, Wolf Y et al: Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol 37:1839-45, 2001. OBJECTIVES: The goal of this study was to investigate the nature of the association between silent ischemia and postoperative myocardial infarction (PMI). BACKGROUND: Silent ischemia predicts cardiac morbidity and mortality in both ambulatory and postoperative patients. Whether silent stress-induced ischemia is merely a marker of extensive coronary artery disease or has a closer association with infarction has not been determined. METHODS: In 185 consecutive patients undergoing vascular surgery, we correlated ischemia duration, as detected on a continuous 12-lead ST-trend monitoring during the period 48 h to 72 h after surgery, with cardiac troponin-I (cTn-I) measured in the first three postoperative days and with postoperative cardiac outcome. Postoperative myocardial infarction was defined as cTn-I >3.1 ng/ml accompanied by either typical symptoms or new ischemic electrocardiogram (ECG) findings. RESULTS: During 11,132 patient-hours of monitoring, 38 patients (20.5%) had 66 transient ischemic events, all but one denoted by ST-segment depression. Twelve patients (6.5%) sustained PMI; one of those patients died. All infarctions were non-Q-wave and were detected by a rise in cTn-I during or immediately after prolonged, ST depression-type ischemia. The average duration ofischemia in patients with PMI was 226+/-164 min (range: 29 to 625), compared with 38+/-26 min (p = 0.0000) in 26 patients with ischemia but not infarction. Peak cTn-I strongly correlated with the longest, as well as cumulative, ischemia duration (r = 0.83 and r = 0.78, respectively). Ischemic ECG changes were completely reversible in all but one patient who had persistent new T wave inversion. All ischemic events culminating in PMI were preceded by an increase in heart rate (delta heart rate = 32+/-15 beats/min), and most (67%) of them began at the end of surgery and emergence from anesthesia. CONCLUSIONS: Prolonged, ST depression-type ischemia progresses to MI and is strongly associated with the majority of cardiac complications after vascular surgery.
Lee ES, Santilli SM, Olson MH, Kuskowski MA, Lee JT: Wound Infection After Infrainguinal Bypass Operations: Multivariate Analysis of Putative Risk Factors. Surgical Infections 1: 257-263, 2000. Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but there is limited appreciation of which characteristics of patients or operations are reliable markers of increased wound infection risk. The purpose of the present study was to analyze all wound infections observed after infrainguinal bypass operations during 20 years of practice in a large teaching institution. Independent risk factors for wound infection development were identified. During the 20-year period ending 31 December, 1997, 978 male patients underwent infrainguinal bypass operations at the Minneapolis Department of Veterans Affairs Medical Center. Wound infections complicated the recovery of 129 of these patients during a 30-day postoperative surveillance interval. Multivariate logistic regression analysis was used to test the association between wound infection occurrence and putative risk factors that were either features of patients or characteristics of the operations. The following variables were examined: obesity, prosthetic graft placement, diabetes mellitus, steroid use, anticoagulation use, length of preoperative hospital stay, development of incisional hematoma, duration of operation, and the preoperative presence of a non-healing wound in the extremity being revascularized. The overall wound infection rate was 13.2% (129/978). In a final logistic regression model, obesity was a significant and independent predictor of wound infection (Relative Risk 2.6, 95% confidence interval, 1.35-4.90), as was development of a post-operative incisional hematoma (Relative Risk 6.44, 95% confidence interval, 2.95-14.08). No other explanatory variable was significantly associated with wound infection development.
Leng GC, Davis M, Baker D: Bypass surgery for chronic lower limb ischemia. Cochrane Database Syst Rev. 2000; (3):CD002000. BACKGROUND: Surgical bypass of an occluded arterial segment is the mainstay of treatment for patients with critical limb ischaemia. As with many surgical interventions, however, it was introduced without formal evaluation. OBJECTIVES: The objective of this review was to determine the effects of bypass surgery in patients with chronic lower limb ischaemia. SEARCH STRATEGY: The reviewers searched the Cochrane Peripheral Vascular Diseases Group trials register, MEDLINE, EMBASE, reference lists of relevant articles, and contacted principal trial investigators. SELECTION CRITERIA: All randomised controlled trials of bypass surgery versus control, or versus any other form of treatment. DATA COLLECTION AND ANALYSIS: At least two reviewers extracted data and assessed trial quality independently. The reviewers contacted investigators to obtain information or data needed for the review that could not be found in published reports. Dichotomous data were analysed using the Peto odds ratio (OR), and continuous data with the weighted mean difference (fixed effect and random effects models). MAIN RESULTS: Eight trials were identified which appeared to meet the inclusion criteria, but two were subsequently excluded. The remaining six trials involved a total of just over 700 patients, two trials comparing bypass surgery with angioplasty (PTA), and one with each of thromboendarterectomy, thrombolysis, exercise, and spinal cord stimulation. Four trials included patients with a range of disease severity (intermittent claudication and critical limb ischaemia), one was restricted to claudicants only and another to only critical limb ischaemia. The type of bypass procedure performed in each trial was similar: vein grafts for distal reconstructions; synthetic prostheses for aorto-iliac or ilio-femoral bypasses. The outcome measures varied, but four of the six trials included mortality and operative failure. In general the quality of the trials was good, but none was blinded because of the nature of the intervention. There were no clear differences between bypass surgery and PTA. Mortality and amputation rates did not differ significantly, although primary patency was significantly higher in the bypass group after 12 months (Peto OR 1. 6, 95% CI 1.0, 2.6) but not after four years (p=0.14). Compared with thrombolysis, amputation rates were significantly lower in the bypass group (Peto OR 0.2, 95% CI 0.1, 0.6), but mortality rates did not differ. Compared with thromboendarterectomy, restoration of blood flow was significantly greater in the bypass patients (Peto OR 9.2, 95% CI 1.7, 50.6), but mortality and amputation rates did not differ. Bypass did not differ significantly from exercise or spinal cord stimulation. REVIEWER'S CONCLUSIONS: There is limited evidence for the effectiveness of bypass surgery and further large trials are required.
Lette J, Waters D, Lassonde J et al: Postoperative myocardial infarction and cardiac death. Predictive value of dipyridamole-thallium imaging and five clinical scoring systems based on multifactorial analysis. Ann Surg 211:84-90, 1990. Abstract: Sixty-six patients unable to complete a standard preoperative exercise test because of physical limitations were studied to determine the predictive value of individual clinical parameters, of clinical scoring systems based on multifactorial analysis, and of dipyridamole-thallium imaging before major general and vascular surgery. Study endpoints were limited to postoperative myocardial infarction or cardiac death before hospital discharge. There were nine postoperative cardiac events (seven deaths and two nonfatal infarctions). There was no statistical correlation between cardiac events and preoperative clinical descriptors, including individual clinical parameters, the Dripps-American Surgical Association score, the Goldman Cardiac Risk Index score, the Detsky Modified Cardiac Risk Index score, Eagle's clinical markers of low surgical risk, and the probability of postoperative events as determined by Cooperman's equation. There were no cardiac events in 30 patients with normal dipyridamole-thallium scans or in nine patients with fixed myocardial perfusion defects. Of 21 patients with reversible perfusion defects who underwent surgery, nine had a postoperative cardiac event (sensitivity, 100%; specificity, 43%). In the six other patients with reversible defects, preoperative angiography showed severe coronary disease or cardiomyopathy. Thus in patients unable to complete a standard exercise stress test, postoperative outcome cannot be predicted clinically before major general and vascular surgery, whereas dipyridamole-thallium imaging successfully identified all patients who sustained a postoperative cardiac event.
Lin PH, Bush RL, Conklin BS, Chen C, Weiss VJ, Chaikof EL, Lumsden AB. Late complication of aortoiliac stent placement - atheroembolization of the lower extremities. J Surg Res 103:153-9, 2002. BACKGROUND: Atheroembolization following aortoiliac stent placement is uncommon. The purpose of this study was to examine the management and risk factors of lower extremity atheroembolization following aortoiliac stent placement for occlusive disease. MATERIALS AND METHODS: From March 1993 to February 2001, the hospital records of all patients who developed thromboembolic events following aortoiliac stent placement were reviewed. Risk factor analysis was performed by comparing with the control group, which consisted of 493 patients treated with aortoiliac stents during the study period who did not develop atheroembolic complications. Patients with cardiac etiologies or aortic aneurysms as the source of embolization as well as those who developed acute embolization following stent deployment (<30 days) were excluded. RESULTS: Atheroembolization occurred in eight patients (12 iliac artery stents and 1 aortic stent) at intervals ranging from 9 to 43 months (mean 22 months) following aortoiliac stent placement. Arteriography in all patients implicated the stented artery as the source of atheroembolism. Five corrective operations (two aorto-bifemoral bypasses, one ileofemoral bypass, and two aortoiliac endarterectomies) along with two concomitant femoropopliteal thrombectomies were performed successfully in five patients. The remaining three patients were treated with either thrombolysis and/or additional stent placement, which resulted in either iliac occlusion or recurrent embolic symptoms (P < 0.05). All 3 patients subsequently underwent bypass procedures (one ileofemoral and two femorofemoral bypasses). There was no perioperative mortality. During a mean follow-up of 16 months (range 3 to 45 months), two patients required minor amputations, whereas one required major leg amputation. No further episodes of atheroembolism occurred in the involved limbs following surgical bypass procedures. Risk factor analysis failed to identify potential variables that correlated with atheroembolism following aortoiliac stent placement. CONCLUSION: Patients with atheromatous embolization following aortoiliac stent placement should be evaluated aggressively. The treatment of choice is surgical correction or bypass with exclusion of the offending embolic source. Although intra-arterial stent placement in the atheroembolic stented iliac artery is feasible, it may provide a less durable result.
Littooy FN, Steffan G, Steinam S, Saletta C and Greisler HP: An 11-year experience with aortofemoral bypass grafting. Cardiovasc Surgery 1:232-238, 1993. Abstract: Over the past 11 years, 224 patients (440 limbs) underwent aortofemoral bypass grafting for claudication (63%), or limb-threatening ischemia (37%). The distal anastomosis included the profunda femoris artery directly or only as a profundoplasty in 163 limbs (37.0%). Concomitant distal bypasses were carried out in 19 limbs (4.3%). The perioperative mortality rate was 4.9%; over half of the deaths (six) were from myocardial infarction. There were ten early graft limb occlusions (2.3%). Only five major amputations (1.1%) occurred. Long-term follow-up of 416 limbs averaged 58.5 (range 2-142) months. Cumulative primary and secondary patency rates were 88 and 93% respectively at 5 years, and 73% and 89% respectively at 10 years. The cumulative limb salvage rate was 95% at 5 years and 91% at 10 years. Improvement of claudication or relief from limb-threatening ischemia occurred in 90% of limbs early after treatment. Only 5.9% of limbs were worse after operation. During follow-up, 55 patients (38.5%) died, over half from cardiac causes. Long-term graft-related complications included pseudoaneurysm in 16 limbs (3.8%) and graft limb thrombosis in 33 (7.9%), occurring at a mean of 57.8 and 24.8 months respectively. Graft infection occurred in four patients (1.9%). Excluding operations for graft infection, the operative mortality rate in 72 reoperations on 45 patients was 5.5%. In summary, aortofemoral bypass grafting can be performed safely with long-term patency and limb salvage rates. Improvements in the perioperative mortality rate could best be addressed by improvements in cardiac evaluation and perioperative monitoring. Long-term graft limb complications do occur and, therefore, these patients require lifetime surveillance. Comments: Indications for operation in these patients were claudication 62.9%, rest pain 23.7%, non-healing ulcers 9.4% and gangrene 4%. The latter three categories generally signify more ischemia than the claudication group, but still did well.
Lofberg AM, Karacagil S, Ljungman C et al: Percutaneous transluminal angioplasty of the femoropopliteal arteries in limbs with chronic critical lower limb ischemia. J Vasc Surg 34: 114-21, 2001. PURPOSE: The aim of the study was to evaluate the results of percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries in patients with subcritical or critical lower limb ischemia. Materials and Methods: Ninety-two patients underwent 121 PTA procedures, 68 were of the superficial femoral artery (SFA), 13 of the popliteal and 40 of both arteries. Fifty-seven procedures were performed for treatment of occlusions. Eighty-four patients (94 procedures) were monitored with duplex scanning. RESULTS: Technical success rate was 88%. Primary success rates at 12 and 60 months in the whole series were 40% and 27%, respectively. The primary success rate in limbs with SFA occlusion of longer than 5 cm was only 12% after 5 years compared with 32% if the occlusion was less than/equal to 5 cm in length (P <.01). The primary success rate at 60 months was 53% in limbs with single SFA stenosis and 42% in those with multiple stenoses (P = NS). Limb salvage rate for combined endovascular and vascular interventions was 86% at 5 years. The overall survival rate was 51% at 5 years. CONCLUSION: The results of femoropopliteal PTA performed for treatment of subcritical or critical lower limb ischemia seemed to be inferior to the results of infrainguinal bypass grafting reported in literature. However, because the PTA procedure does not preclude the performance of bypass grafting, it might be an alternative to surgical intervention in limbs with stenotic femoropopliteal lesions. PTA might also be considered in patients with high surgical risk and limited life expectancy, having short occlusive lesions (< 5 cm).
Lopez-Galarza LA, Ray LI, Rodriguez-Lopez J and Diethrich EB: Combined percutaneous transluminal angioplasty, iliac stent deployment, and femorofemoral bypass for bilateral aortoiliac occlusive disease. In their title, the authors describe their option for treating iliac occlusion and contralateral iliac stenosis of less than 3cm in length when other circumstances make the avoidance of an abdominal incision desirable. Comments: We are sometimes asked to boot patients with iliac disease who are inoperable because of age, severe hea