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ABSTRACT: Infrainguinal bypass (IB) surgery is an effective means of improving arterial circulation to the lower extremity for patients with critical limb ischemia (CLI). However, wound complications (WC) of the surgical incision following IB can impart significant morbidity.
A retrospective analysis of WC from the 1404 patients enrolled in a multicenter clinical trial of vein bypass grafting for CLI was performed. Univariate and multivariable regression models were used to determine WC predictors and associated outcomes, including graft patency, limb salvage, quality of life (QoL), resource utilization (RU), and mortality.
A total of 543 (39%) patients developed a reported WC within 30 days of surgery, with infections (284, 52%) and hematoma/hemorrhage (121, 22%) being the most common type. Postoperative anticoagulation (odds ratio [OR], 1.554; 95% confidence interval [CI] 1.202 to 2.009; P = .0008) and female gender (OR, 1.376; 95% CI, 1.076 to 1.757; P = .0108) were independent factors associated with WC. Primary, primary-assisted, and secondary graft patency rates were not influenced by the presence of WC; though, patients with WC were at increased risk for limb loss (hazard ratio [HR], 1.511; 95% CI 1.096 to 2.079; P = .0116) and higher mortality (HR, 1.449; 95% CI 1.098 to 1.912; P = .0089). WC was not significantly associated with lower QoL at 3 months (4.67 vs 4.79, P = .1947) and 12 months (5.02 vs 5.13, P = .2806). However, the subset of patients with serious WC (SWC) demonstrated significantly lower QoL at 3 months compared with patients without WC, (4.43 vs 4.79, respectively, P = .0166), though this difference was not seen at 12 months (4.94 vs 5.13, P = .2411). Patients with WC had higher RU than patients who did not have WC. Mean index length of hospital stay (LOS) was 2.3 days longer, mean cumulative 1-year LOS was 8.1 days longer, and mean number of hospitalizations was 0.5 occurrences greater for patients with WC compared with patients without WC (all P < .0001).
WC is a frequent complication of IB for CLI, associated with increased risk for major amputation, mortality, and greater RU. Further detailed investigation into the link between female gender and oral anticoagulation use with WC may help identify causes of WC and perhaps prevent or lessen their occurrence.
Journal of Vascular Surgery 01/2008; 46(6):1191-1197. · 3.21 Impact Factor
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ABSTRACT: The influence of operator-dependent variables on the outcomes of lower extremity bypass (LEB) surgery have primarily been reported in single-institution, retrospective studies. We utilized data from a prospective, multicenter trial to identify technical variables that were significantly associated with early and midterm results of autogenous LEB for limb salvage.
The PREVENT III trial database includes 1404 North American patients with critical limb ischemia (CLI) who underwent LEB using excised autogenous vein. The study protocol excluded claudicants and in situ reconstructions. Technical factors analyzed included vein diameter, conduit type, graft length, vein orientation, location of proximal and distal anastomoses, and performance of completion imaging. Univariate analysis was used to determine the effect of these factors on 30 day and 1-year outcomes. Multivariate Cox regression models evaluated the influence of these factors while adjusting for age, sex, race, tobacco, diabetes, dialysis-dependency, previous index limb bypass, and study drug (edifoligide) administration. The primary outcomes were primary patency (PP), primary assisted patency (PAP), and secondary patency (SP) assessed by Kaplan-Meier method.
Univariate analysis revealed that vein diameter <3.5 mm and composite graft type were significantly associated with early (30 day) graft failure. At 1 year, multivariate analysis revealed that patency rates were negatively associated with diameter <3.5 mm (PP, PAP, SP), non-great saphenous vein (GSV) type (PP, SP), and graft lengths >50 cm (PP only). Limb salvage and survival at 1 year were not significantly impacted by technical variables. Employing a prespecified trial definition of high-risk conduits (diameter <3mm or nonsingle segment GSV; 24% of entire cohort) revealed that use of such conduits was associated with a 2.1-fold increased risk of 30 day graft failure (P < .05), as well as reduced PP, PAP, and SP at 1 year. Use of a high-risk conduit was also associated with an increased index length of stay (mean 9.37 vs 8.71 days, P = .03) and a greater number of reinterventions (mean 0.67 vs 0.42, P < .0001) over the ensuing year.
In this large, multicenter cohort of patients undergoing LEB for CLI, vein diameter and conduit type were the dominant technical determinants of early and late graft failure. High-risk conduits and longer grafts may benefit from aggressive postoperative graft surveillance.
Journal of Vascular Surgery 01/2008; 46(6):1180-90; discussion 1190. · 3.21 Impact Factor
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ABSTRACT: End-stage renal disease (ESRD) imparts a significant survival disadvantage to individuals undergoing lower extremity revascularization; however, the influence of lesser degrees of renal impairment remains unclear. This study examined the prognostic significance of the chronic kidney disease (CKD) classification on survival, limb salvage, and graft patency in patients undergoing lower extremity arterial reconstruction.
A prospective registry was evaluated for consecutive patients between January 31, 1995, and December 21, 2004, undergoing first-time, lower extremity vein bypass surgery. Glomerular filtration rate (GFR) was estimated with the Modification of Diet in Renal Disease equation using each patient's preoperative creatinine concentration. CKD categories were taken from current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria.
The cohort included 456 subjects, with a mean (+/- SD) age of 68.1 +/- 10.8 years. There were 274 men (60%) and 378 Caucasians (82.5%). Comorbidities included diabetes mellitus in 270 (59.0%), hypertension in 333 (72.7%), coronary artery disease in 242 (52.8%), and dyslipidemia in 203 (44.5%). The surgical indication was critical limb ischemia in 384 (83.8%). Among the variables examined, diabetes and critical ischemia as the indication for bypass were significantly skewed toward higher CKD classifications (P < .001). The 5-year survival rates by CKD class were, CKD 1 and 2, 57%; CKD 3, 46%; CKD 4, 23%; and CKD 5, 9.5%. On univariate analysis, age, coronary artery disease, diabetes mellitus, hypertension, critical ischemia, and CKD were significant predictors of mortality. After adjustment, however, only age (hazard ratio [HR], 1.05, 95% confidence interval [CI], 1.03 to 1.06) and CKD stages 4 (HR, 4.23; 95% CI, 2.04 to 8.75) and 5 (HR, 3.27; 95% CI, 1.96 to 5.45) retained significance. Subjects within the CKD 5 classification were more likely to have a major amputation (P = .018) compared with all other CKD classes. Notably, no relationship was detected between CKD category and graft patency.
CKD staging adequately differentiates survival curves and risk for major amputation among patients with renal impairment who are undergoing lower extremity bypass surgery. This may help in clinical decision analysis as well as in the refinement of stratification in future clinical trial design where survival is an end point.
Journal of Vascular Surgery 05/2007; 45(5):944-52. · 3.21 Impact Factor
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ABSTRACT: Iliac angioplasty in preparation for an infrainguinal bypass graft has been shown to be an effective strategy. We undertook this study to determine if superficial femoral artery (SFA) angioplasty offers durable inflow for distal origin grafts originating from the SFA or popliteal artery.
All distal origin grafts performed at a single institution between 1988 and 2006, </=30 days of an ipsilateral SFA percutaneous intervention, were reviewed retrospectively. Patients were identified from a computerized vascular registry, and data were obtained by review of patient charts, angiograms, and duplex studies.
We identified 23 autogenous distal origin grafts procedures performed distal to an SFA intervention, of which 22 were performed for critical limb ischemia (96%). The SFA lesions intervened on (20 angioplasty alone, 3 angioplasty with stenting) included 11 TransAtlantic Inter-Society Consensus (TASC) A (48%), seven TASC B (30%), five TASC C (22%), and no TASC D (0%). Of the bypasses, five originated from the distal SFA, five originated from the above knee popliteal artery, and 13 originated from the below knee popliteal artery. A significant majority of the patients (87%) were diabetic. No deaths, amputations, or early graft failures occurred during the perioperative period. The mean duration of follow-up was 40.8 months. By life-table analysis, the primary patency rate was 58% at 5 years. The primary assisted patency rate was 69% at 5 years. Of the seven interventions required to maintain patency, only one targeted the SFA. None of the graft failures could be specifically attributed to disease progression of the SFA. The 5-year limb salvage rate was 70% and the survival rate was 65%.
Percutaneous SFA intervention in preparation for a distal origin graft is a useful and effective strategy in select patients. The durability appears comparable with distal origin grafts performed in the absence of an SFA intervention. This strategy provides a good option in the setting of both atherosclerotic SFA disease and limited autogenous conduit.
Journal of Vascular Surgery 04/2007; 45(4):740-3. · 3.21 Impact Factor
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ABSTRACT: As the associated risks of infrainguinal balloon angioplasty and stenting have fallen and the relative success rates have risen in recent years, the threshold for offering endovascular treatment to patients with claudication has significantly decreased. Patients once considered appropriate only for risk-factor modification, exercise therapy, and medical treatment are now increasingly being offered percutaneous revascularization as a primary treatment option. Similarly, occlusive disease of the tibial vessels, once thought to be the exclusive domain of operative bypass, is increasingly being treated percutaneously. Over this same period, results of operative infrainguinal arterial reconstruction have also considerably improved. In modern times, excellent outcomes following bypass grafting with autogenous vein to the tibial level have been demonstrated, with morbidity, mortality, and long-term patency equivalent to that of more proximal bypasses. Evidence supports the view that the anatomic level of the distal anastomosis is less critical to the long-term outcome of the procedure than factors such as operative indication and conduit quality. Within the context of this changing climate, it is an appropriate time to examine and potentially redefine the role of both endovascular and open surgical intervention for a population that has not traditionally been offered revascularization, patients with claudication secondary to infrageniculate occlusive disease.
Seminars in Vascular Surgery 04/2007; 20(1):42-53. · 1.71 Impact Factor
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ABSTRACT: Inflammatory markers such as high-sensitivity C-reactive protein (hsCRP) are associated with an increased risk of cardiovascular events and with the severity of peripheral arterial disease. The effects of inflammation on the development of vein graft disease remain speculative. We hypothesized that high levels of inflammatory markers would identify patients at increased risk for adverse events (graft failure, major cardiovascular events) after lower extremity bypass surgery.
Patients (n = 91) scheduled to undergo lower extremity bypass using autogenous vein were enrolled into a prospective study at two institutions. Exclusion criteria included the presence of major infection. A baseline plasma sample was obtained on the morning of lower extremity bypass. Biomarkers for inflammation included hsCRP, fibrinogen, and serum amyloid A (SAA). Values between patients with and without critical limb ischemia were compared. Proportions of events among dichotomized populations (upper limit of normal of each laboratory assay) were compared by log-rank test.
Of the patients undergoing lower extremity bypass, 69% were men, 53% were diabetic, 81% were smokers, and their mean ankle-brachial index was 0.51 +/- 0.19. The indication for lower extremity bypass was critical limb ischemia in 55%. There were no perioperative deaths and two early graft occlusions. During a mean follow-up of 342 days (range, 36-694 days) there were four deaths, 27 graft-related events, and 10 other cardiovascular events. No relationships were found between events and demographics, comorbidities, baseline ankle-brachial index, or statin use. High-sensitivity CRP (P = .005), fibrinogen (P < .001), and SAA (P = .0001) levels were associated with critical limb ischemia at presentation. Among patients with an elevated hsCRP (>5 mg/L) immediately before surgery, major postoperative vascular events occurred in 60% (21/35), compared with a 32% (18/56) rate in those with a baseline CRP <5 mg/L (P = .004, log-rank test). On multivariable analysis, only elevated hsCRP correlated with adverse graft-related or cardiovascular events (P = .018).
The inflammatory biomarkers of hsCRP, fibrinogen, and SAA correlate with peripheral arterial disease severity at presentation in patients undergoing lower extremity bypass. Patients with elevated hsCRP are at increased risk for postoperative vascular events, most of which are related to the vein graft. These findings suggest a potential relationship between inflammation and outcomes after lower extremity vein bypass surgery.
Journal of Vascular Surgery 02/2007; 45(1):2-9; discussion 9. · 3.21 Impact Factor
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ABSTRACT: Resource utilization (RU) in the care of patients with critical limb ischemia (CLI) is not well quantified. We present a cohort study to quantify in-hospital RU and analyze the role of tissue loss (TL), comorbidities, and vascular graft-related events (GREs) in patients undergoing peripheral bypass for CLI.
A retrospective analysis of 1404 patients enrolled in a multicenter clinical trial (PREVENT III) of vein bypass grafting for CLI was performed with analysis of RU during the 1-year follow-up period. Univariate and multivariable linear regressions were performed to determine RU predictors and outcomes.
Compared with patients with rest pain, patients presenting with TL as the indication for bypass surgery had a longer index length of stay (mean, 9.8 vs 6.2 days), more rehospitalizations (mean, 1.6 vs 1.2), and a longer cumulative length of stay (mean, 27.7 vs 17.3 days; P < .0001 for all comparisons). Rehospitalizations over the ensuing year were for additional procedures (37.5%), wound infection (14.6%), graft failure (10.7%), and other cardiovascular (10%) and noncardiovascular (26%) reasons. Early GRE (stenosis > or =70%, thrombosis, revision, or major amputation within 30 days) occurred in 162 (11.5%) patients, resulting in a longer index length of stay (mean, 11.8 vs 8.6 days; P = .0002) and cumulative length of stay (mean, 25.9 vs 24.6 days; P = .0043), but no difference in the number of rehospitalizations (mean, 1.6 vs 1.5 days; P = .3272). During the 1-year follow-up, 554 (39.5%) patients had GREs, and this resulted in more rehospitalizations (mean, 2.1 vs 1.1; P < .0001) and a longer cumulative length of stay (mean, 28.2 vs 21.9 days; P < .0001) compared with patients without GRE. Multivariable analysis demonstrated the highly positive association of TL (hazard ratio [HR], 1.75) and early GRE (HR, 1.77) with the index length of stay, whereas comorbidities-namely, dialysis dependency (HR, 1.31), nonsmoking status (HR, 1.29), hypertension (HR, 1.26), and increasing age (HR, 1.01)-also had strong effects. The effect of TL and GRE on later RU (number of rehospitalizations and cumulative length of stay) was present but less pronounced than patient comorbidities (namely, dialysis).
The stage of disease at presentation (TL vs rest pain) and the patency of the bypass graft (freedom from GRE) are critical determinants of RU over the first year after limb-salvage surgery. These effects predominate early (index length of stay) and persist through 1 year. Patient-specific factors, particularly dialysis-dependent renal failure, are also critical comorbidities affecting RU in these patients.
Journal of Vascular Surgery 12/2006; 44(5):971-5; discussion 975-6. · 3.21 Impact Factor
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ABSTRACT: The geometric and biomechanical changes that contribute to vein graft remodeling are not well established. We sought to measure patterns of adaptation in lower extremity vein grafts and assess their correlation with clinical outcomes.
We conducted a prospective, longitudinal study of patients undergoing infrainguinal reconstruction with autogenous conduit. In addition to standard duplex surveillance, lumen diameter (of a defined index segment of the conduit) and pulse wave velocity (PWV) were assessed by ultrasound imaging at surgery and at 1, 3, and 6 months postoperatively. Graft dimensions and wall stiffness were correlated with clinical outcomes.
There were 92 patients and 96 limbs in this study. On average, vein graft lumen diameter increased during the first month of implantation from 0.37 +/- .01 cm to 0.45 +/- 0.02 cm (mean +/- SEM; P = .002), representing a relative change of +21.6% (median +/- 14%; range, -31 to +67%) during this period. Of the entire cohort, 72% of grafts demonstrated appreciable dilation of the index segment during the first month. Index segment lumen diameter did not change appreciably beyond 1 month, with the notable exception of arm vein conduits, which showed continued tendency to dilate. PWV increased during the first 6 months (17.2 +/- 1.2 m/s to 23.2 +/- 2.4 m/s; P = .008), reflecting a nearly 40% increase in conduit stiffness (2.0 +/- .6 Mdynes/cm to 3.3 +/- .8 Mdynes/cm, P = .01). The greatest relative increase (25%) in PWV occurred from months 1 to 3. Loss of primary patency occurred in 24 cases (19 revisions, 5 occlusions), with a mean reintervention time of 7.6 months. Grafts that demonstrated early positive remodeling (lumen dilatation) had a trend of increased primary patency (P = .08, log rank). Among the grafts that failed, a trend was noted toward greater wall stiffness at 1 month, 2.7 vs 1.5 Mdynes (P = .08).
Vein graft remodeling appears to involve at least two distinct temporal phases. Outward remodeling of the lumen occurs early, and wall stiffness changes occur in a more delayed fashion. Early outward remodeling may be important for successful vein graft adaptation.
Journal of Vascular Surgery 11/2006; 44(4):740-6. · 3.21 Impact Factor
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ABSTRACT: Renal venous thrombosis most commonly occurs in the setting of nephrotic syndrome, hypercoagulability, or dehydration. This can usually be treated with systemic anticoagulation, and the diversion is via natural draining tributaries, eg, adrenal, lumbar, or gonadal veins. Occasionally, renal venous thrombosis results from extension of a thrombotic process, such as a large renal cell carcinoma with tumor thrombus extension into the infrahepatic inferior vena cava resulting in thrombosis of the inferior vena cava and contralateral renal vein. Herein, we report a case of left renal vein thrombosis relieved by diversion through the inferior mesenteric vein.
Journal of Vascular Surgery 07/2006; 43(6):1283-6. · 3.21 Impact Factor
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Michael S Conte,
Dennis F Bandyk,
Alexander W Clowes,
Gregory L Moneta,
Lynn Seely,
Todd J Lorenz,
Hamid Namini,
Allen D Hamdan,
Sean P Roddy, Michael Belkin,
Scott A Berceli,
Richard J DeMasi,
Russell H Samson,
Scott S Berman
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ABSTRACT: The PREVENT III study was a prospective, randomized, double-blinded, multicenter phase III trial of a novel molecular therapy (edifoligide; E2F decoy) for the prevention of vein graft failure in patients undergoing infrainguinal revascularization for critical limb ischemia (CLI).
From November 2001 through October 2003, 1404 patients with CLI were randomized to a single intraoperative ex vivo vein graft treatment with edifoligide or placebo. After surgery, patients underwent graft surveillance by duplex ultrasonography and were followed up for index graft and limb end points to 1 year. A blinded Clinical Events Classification committee reviewed all index graft end points. The primary study end point was the time to nontechnical index graft reintervention or major amputation due to index graft failure. Secondary end points included all-cause graft failure, clinically significant graft stenosis (>70% by angiography or severe stenosis by ultrasonography), amputation/reintervention-free survival, and nontechnical primary graft patency. Event rates were based on Kaplan-Meier estimates. Time-to-event end points were compared by using the log-rank test.
Demographics, comorbidities, and procedural details reflected a population with CLI and diffuse atherosclerosis. Tissue loss was the presenting symptom in 75% of patients. High-risk conduits were used in 24% of cases, including an alternative vein in 20% (15% spliced vein and 5% non-great saphenous vein) and 6% less than 3 mm in diameter; 14% of the cases were reoperative bypass grafts. Most (65%) grafts were placed to infrapopliteal targets. Perioperative (30-day) mortality occurred in 2.7% of patients. Major morbidity included myocardial infarction in 4.7% and early graft occlusion in 5.2% of patients. Ex vivo treatment with edifoligide was well tolerated. There was no significant difference between the treatment groups in the primary or secondary trial end points, primary graft patency, or limb salvage. A statistically significant improvement was observed in secondary graft patency (estimated Kaplan-Meier rates were 83% edifoligide and 78% placebo; P = .016) within 1 year. The reduction in secondary patency events was manifest within 30 days of surgery (the relative risk for a 30-day event for edifoligide was 0.45; 95% confidence interval, 0.27-0.76; P = .005). For the overall cohort at 1 year, the estimated Kaplan-Meier rate for survival was 84%, that for primary patency was 61%, that for primary assisted patency was 77%, that for secondary patency was 80%, and that for limb salvage was 88%.
In this prospective, randomized, placebo-controlled clinical trial, ex vivo treatment of lower extremity vein grafts with edifoligide did not confer protection from reintervention for graft failure.
Journal of Vascular Surgery 05/2006; 43(4):742-751; discussion 751. · 3.21 Impact Factor
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ABSTRACT: The presence of an abdominal aortic aneurysm (AAA) can be a contraindication to placement of a HeartMate left ventricular assist device (LVAD) for end-stage heart failure. We describe a 65-year-old patient who underwent endovascular repair of an AAA before placement of a LVAD as destination therapy for end-stage heart failure. This case is the first report of endovascular AAA repair before VAD placement. It not only demonstrates the utility of endovascular AAA repair in patients with undue co-morbidities, but also that the presence of an AAA should not be a contraindication to LVAD placement, if corrected.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 03/2006; 25(2):253-5. · 3.54 Impact Factor
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Perspectives in Vascular Surgery and Endovascular Therapy 01/2006; 17(4):381-2.
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ABSTRACT: African Americans (AAs) are at risk for developing diabetes mellitus and atherosclerosis. Whether race influences the results of infrainguinal arterial reconstruction is unclear. The purpose of this study was to compare the results of autogenous infrainguinal bypasses in AAs and Caucasians to determine the association of race with graft function and limb salvage.
This was a retrospective, comparative cohort study of AA and Caucasian patients who had undergone autogenous infrainguinal bypass surgery. Only single-limb bypasses in each patient cohort were considered in this analysis. In patients who had undergone bilateral lower limb bypasses, the first limb bypass was chosen as the index bypass procedure.
From January 1985 to December 2003, 1459 autogenous infrainguinal bypasses were performed in 1459 patients for lower limb ischemia. Within this group, 89 AA patients/vein grafts formed the study cohort. The control group comprised 1370 Caucasian patients/vein grafts. Compared with the Caucasian cohort, AA patients were significantly younger (median age, 65 vs 70 years, respectively; P = .001) and predominantly female (57% vs 41%, respectively; P = .002). AA patients also had a higher prevalence of diabetes mellitus, hypertension, cerebrovascular disease, congestive heart failure, and dialysis-dependent renal failure. More AA than Caucasian patients presented with gangrene (34% vs 16%, respectively; P = .001), and more underwent bypass surgery for limb salvage indications (91% vs 81%, respectively; P = .01). The venous conduit used was predominantly the greater saphenous vein (AA, 83%; Caucasian, 85%), and the site of distal anastomosis was at the tibial/pedal level in 67% of AA and 61% of Caucasian patients. Overall morbidity (AA, 28%; Caucasian, 23%) and 30-day mortality (AA, 3%; Caucasian, 3%) were similar. Thirty-day graft failure was significantly greater in AAs than Caucasians (12% vs 5%, respectively; P = .003). The overall 5-year primary graft patency (+/-SE) was significantly worse in AA patients (AA, 52% +/- 6%; Caucasian, 67% +/- 2%; P = .009). The 5-year limb salvage rate (+/-SE) was also significantly worse in AA patients (AA, 81% +/- 5%; Caucasian, 90% +/- 1%; P = .04). With the Cox proportional hazard model, significant risk factors associated with primary graft failure were AA race, age younger than 65 years, female sex, secondary reconstructions, tibial bypasses, and critical limb ischemia. Significant risk factors associated with limb loss were age younger than 65 years, female sex, absence of coronary disease, presence of critical limb ischemia, and secondary reconstructions.
Autogenous infrainguinal bypass surgery in AAs is associated with poorer primary graft patency and limb salvage rates compared with those of Caucasians. This may partially account for the higher rate of limb loss in AA patients with peripheral arterial occlusive disease.
Journal of Vascular Surgery 11/2005; 42(4):695-701. · 3.21 Impact Factor
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ABSTRACT: We sought to determine the long-term results of revision procedures performed for repair of stenotic lesions in infrainguinal vein bypass grafts.
A retrospective review of 188 vein grafts, from a total series of 1260 bypasses, undergoing revision of stenotic lesions between January 1, 1987, and December 31, 2002, at Brigham & Women's Hospital was undertaken. Lesions were identified by recurrence of symptoms, change in examination findings, or with routine duplex ultrasound graft surveillance. Demographic and medical risk factors, and surgical variables were analyzed with respect to patency outcomes after the initial graft revision, with descriptive statistics, logistic regression, and life table analysis. Primary and secondary patency rates were determined from the time of graft revision.
Patients included 108 men (57%) and 80 women (42%) who underwent revision at a mean age of 67.8 years. One hundred thirty grafts required only a single revision, whereas 58 required subsequent additional revisions. Revision procedures included 99 vein patches (52.7%), 23 jump grafts (12.2%), 23 interposition grafts (12.2%), 8 transpositions to new outflow vessels (4.3%), and 35 balloon angioplasty procedures (18.6%). During a mean follow-up of 1535 days, 5-year primary patency rate was 49.3% +/- 4.5% (SE) and 5-year secondary patency rate was 80.3% +/- 3.6%. There was no difference in patency rate for different revision procedures, type of vein graft, indication for the original procedure, or for patients with diabetes mellitus or renal disease. The overall limb salvage rate was 83.2% +/- 3.5% 5 years after graft revision. With COX proportional hazard analysis of time to failure of the revision procedure, the outflow level of the original bypass and the time of revision proved to be an important predictor of durability of the graft revision. Revision of popliteal bypass grafts resulted in a 60% 5-year primary patency rate, whereas revision of tibial grafts resulted in a 42% 5-year primary patency rate (P = .004; hazard ratio [HR], 2.06). Five-year secondary patency rates were 90% and 76%, respectively (P = .009; HR = 3.43). The timing of the graft revision proved an additional predictor. Grafts revised within 6 months of the index operation had lower primary patency than those with later revisions (42.9% vs 80.7%, respectively; HR = 1.754; P = .0152).
Vein graft revisions offer durable patency and limb salvage rates after repair of stenotic infrainguinal bypass grafts. Vigilant ongoing surveillance is essential, because 30.9% of revised grafts will develop additional lesions that will require repair. Tibial level bypass grafts that require early repeat intervention to treat graft stenosis are at particular risk for development of subsequent lesions.
Journal of Vascular Surgery 11/2004; 40(5):916-23. · 3.21 Impact Factor
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ABSTRACT: The role of carotid endarterectomy in the prevention of stroke was validated by two randomized clinical trials, the North American Symptomatic Carotid Endarterectomy (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS). However, these trials excluded patients at high risk for perioperative stroke and other morbidity, raising concerns for the applicability of the trial results to the general population. Some have also suggested these "high-risk" patients are better suited for carotid artery stenting with the belief that stenting has lower morbidity and mortality. In this article, we review many of the commonly accepted high-risk factors for carotid endarterectomy (CEA) and examine their outcomes. High-risk patients are more common than generally believed and their outcomes may be the same with carotid endarterectomy as it is with carotid stenting. Truly "high-risk" patients with shortened life expectancy are best served with no intervention.
Seminars in Vascular Surgery 10/2004; 17(3):219-23. · 1.71 Impact Factor
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ABSTRACT: HMG-CoA reductase inhibitors (statins) broadly reduce cardiovascular events, effects that are only partly related to cholesterol lowering. Recent studies suggest important anti-inflammatory and antiproliferative properties of these drugs. The purpose of this study was to determine the influence of statin therapy on graft patency after autogenous infrainguinal arterial reconstructions.
A retrospective analysis of consecutive patients (1999-2001) who underwent primary autogenous infrainguinal reconstructions with a single segment of greater saphenous vein was performed. Patients were categorized according to concurrent use of a statin. Graft lesions (identified by duplex surveillance) and interventions were tabulated. Comparisons between groups were made by using the Fisher exact test for categorical variables and the Student t test for continuous variables. Patency, limb salvage, and survival were compared by log rank test. A stepwise Cox proportional hazards analysis was then employed to ascertain the relative importance of factors influencing graft patency.
A total of 172 patients underwent 189 primary autogenous infrainguinal arterial reconstructions (94 statin, 95 control) during the study period. The groups were well matched for age, indication, and atherosclerotic risk factors. Procedures were performed primarily for limb salvage (92%), with 65% to an infrapopliteal target. Perioperative mortality (2.6%) and major morbidity (3.2%) were not different between groups. There was no difference in primary patency (74% +/- 5% vs 69% +/- 6%; P =.25), limb salvage (92% +/- 3% vs 90% +/- 4%; P =.37), or survival (69% +/- 5% vs 63% +/- 5%; P =.20) at 2 years. However, patients on statins had higher primary-revised (94% +/- 2% vs 83% +/- 5%; P <.02) and secondary (97% +/- 2% vs 87% +/- 4%; P <.02) graft patency rates at 2 years. Of all factors studied by univariate analysis, only statin use was associated with improved secondary patency (P =.03) at 2 years. This was confirmed by multivariate analysis. The risk of graft failure was 3.2-fold higher (95% confidence interval, 1.04-10.04) for the control group. Perioperative cholesterol levels (available in 47% of patients) were not statistically different between groups.
Statin therapy is associated with improved graft patency after infrainguinal bypass grafting with saphenous vein.
Journal of Vascular Surgery 06/2004; 39(6):1178-85. · 3.21 Impact Factor
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ABSTRACT: Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome.
We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping.
Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis.
Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.
Journal of Vascular Surgery 06/2004; 39(6):1163-70. · 3.21 Impact Factor
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ABSTRACT: To quantitatively describe the temporal changes in elastic properties and wall dimensions in lower-extremity vein grafts after implantation.
This is a prospective study of patients (N = 38) undergoing lower extremity bypass grafts (N = 41) with autologous veins. Pulse wave velocity (PWV), luminal diameter, and wall thickness measurements were obtained by duplex ultrasound scan intraoperatively and at 1, 3, and 6 months postoperatively for assessment of graft dimensions and wall stiffness.
Lower extremity vein grafts showed an increase in PWV (from 16 +/- 1 to 21 +/- 3 cm/s; mean +/- SEM; P =.08), reflecting an increase in wall stiffness (from 1.2 +/- 0.2 to 2.5 +/- 0.7 x 10(6) dynes/cm; P =.02) and wall thickness (from 0.47 +/- 0.03 to 0.61 +/- 0.004 mm; P =.04) over the first 6 months after implantation. Changes in lumen diameter were positively correlated with changes in external graft diameter (P <.01) and negatively correlated with initial lumen diameter (P <.01) but not with changes in the wall thickness.
These results suggest complex remodeling of vein grafts during the first several months after implantation, with increased wall thickness occurring independent of variable changes in lumen diameter. Simultaneously, a marked increase in wall stiffness over this interval suggests a likely role for collagen deposition.
Journal of Vascular Surgery 03/2004; 39(3):547-55. · 3.21 Impact Factor
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ABSTRACT: Groin infections adjacent to vascular bypass grafts continue to be a source of morbidity. The authors reviewed retrospectively 9 consecutive patients with early localized groin infections treated at their institution with sartorius or rectus femoris muscle flaps between 1998 and 2002. All wounds were initially opened and drained. Wounds with necrotic tissue were treated with serial surgical debridements, with a vacuum-assisted closure device, or with wet-to-dry dressing changes. Two bypass grafts were excised and replaced in the presence of marked exposure or pseudoaneurysm. Small wounds were closed with a turnover sartorius flap and larger wounds were closed with either a muscle or musculocutaneous rectus femoris flap. Groin wounds healed in all patients without subsequent graft exposure, rupture, or pseudoaneurysm. Local wound therapy with staged debridement and muscle flaps is effective for most early localized graft infections.
Annals of Plastic Surgery 02/2004; 52(1):49-53. · 1.32 Impact Factor
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ABSTRACT: The efficacy of carotid endarterectomy (CEA) for prevention of stroke has been demonstrated in randomized trials; however, the optimal approach in patients excluded from these trials or who have other significant comorbid conditions remains controversial, particularly with the advent of percutaneous interventions. We examined the influence of putative risk factors on outcome of CEA in a single-center experience.
A retrospective analysis of 1370 consecutive CEA performed from 1990 to 1999 was undertaken. Preoperative risk factors examined included age older than 80 years, congestive heart failure, chronic obstructive pulmonary disease, renal failure (serum creatinine concentration > 2.0 mg/dL), contralateral carotid artery occlusion, recurrent ipsilateral carotid artery stenosis, ipsilateral hemispheric symptoms within 6 weeks, and recent coronary bypass grafting (CABG). The Fisher exact test was used to identify baseline variables associated with perioperative (30 days) risk for stroke or death. Multivariate analysis with Poisson regression was used to study the effect of all univariate criteria in combination.
In the overall cohort, there were 32 adverse events (2.3%), including 11 deaths (0.8%), 6 disabling strokes (0.4%), and 10 nondisabling strokes (0.7%). There was no significant difference in incidence of perioperative stroke or death between patients with one or more risk factors (n = 689) and those with no risk factors (low risk, n = 681). Thirty-day mortality was significantly greater in patients with two or more risk factors compared with patients with no risk factors (2.8% vs 0.3%; P =.04), but no significant difference was noted in perioperative stroke rate (2.3% vs 1.0%). Univariate analysis demonstrated that contralateral carotid occlusion (n = 75) was the only significant predictor of adverse outcome (5 events, 6.7%) among the variables tested; this was confirmed with multivariate analysis (relative risk, 4.3; 95% confidence interval, 1.2-12.3; P =.01). Five-year survival for patients with two or more risk factors was notably diminished compared with that for patients with no risk factors (38.7% +/- 5.9% vs 75.0% +/- 2.6%; P <.001). Contralateral occlusion was also associated with reduced 5-year survival (38 +/- 11% vs 67 +/- 2%; P <.004).
CEA can be safely performed in patients deemed at high risk, including those aged 80 years or older and others with significant comorbid conditions, with combined stroke and mortality rates comparable to those found in randomized trials, ie, the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial. Contralateral occlusion may be a predictor for moderately increased perioperative risk and for reduced long-term survival. Caution may be warranted in asymptomatic patients with multiple risk factors, in whom presumed long-term benefit of CEA may be compromised by markedly reduced 5-year survival.
Journal of Vascular Surgery 07/2003; 37(6):1191-9. · 3.21 Impact Factor
