Infrarenal aortic graft infection: in situ aortoiliofemoral reconstruction with the lower extremity deep veins.
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Aged↗
Biomedical subjects
A Nevelsteen
Publications and source records attributed to A Nevelsteen.
Transfemoral treatment for iliac occlusive disease with endoluminal stent-grafts.
OBJECTIVES: Percutaneous treatment of iliac artery occlusive disease has replaced open vascular reconstruction for several indications. A balloon angioplasty with or without stent is not an option in the presence of infrainguinal extension of the disease. The authors describe a technique that allows the construction of an aorto- or iliofemoral graft through a single groin incision, using a 4 mm PTFE graft, anchoring it proximally with a Palmaz stent and dilating both to the desired diameter. DESIGN: Retrospective non-randomised study. MATERIALS AND METHODS: Nineteen procedures were performed in 16 patients mainly because of ischaemic rest pain, often with trophic skin changes or minor gangrene. Three patients had a bilateral procedure. Twelve patients had one or more associated procedures: 10 distal bypasses, one thrombectomy, one reimplantation of a distal bypass on the iliofemoral graft, one contralateral profundaplasty and two stents of the contralateral common iliac artery. RESULTS: Two patients died, one of small bowel ischaemia and the other of a myocardial infarction. During the mean follow-up of 8.8 months, two graft thromboses occurred. In another patient bilateral stenting of a residual stenosis was necessary. CONCLUSIONS: Our experience shows that the reported technique is feasible. Whether the procedure is truly "less invasive" and the long-term results acceptable remains to be shown.
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Inflammatory abdominal aortic aneurysms. A retrospective study of 110 cases.
OBJECTIVE: The purpose of this study is to review our experience with the surgical treatment of 110 patients with an inflammatory abdominal aortic aneurysm (IAAA). Furthermore, we focus especially on 37 ureteral obstructions. PATIENTS AND METHODS: Between 1978 and 1996 we treated 110 patients for an IAAA. It concerned 101 men and nine women with mean age of 66.8 years. Emergency surgery was performed in 32 patients (13 ruptures) and elective surgery in 78 patients (only 23 asymptomatic). The IAAA diagnosis was made by CT scan preoperatively in 40% of the patients. Compression of 37 ureters in 23 patients (14 bilateral, 9 unilateral) was noticed and ureteral stenting was performed preoperatively in nine patients (12 ureters). The surgical approach was median laparotomy (88 patients) or retroperitoneal approach (21 patients). One patient was treated with an endovascular Min-Tec Stentor aortic graft by femoral approach. Suprarenal clamping was necessary in 44 patients. Ureterolysis of 23 ureters was performed. Three peroperative iatrogenic lesions were successfully treated intraoperatively. RESULTS: Fatal complications occurred in nine patients (8%), five patients after urgent surgery and four patients after elective surgery, all of them related to technical problems. Non fatal complications occurred in 22 patients, renal insufficiency was most important in ten patients (two permanent dialysis). The mean follow-up was 4.5 years (range, 0.5 to 15 years). Late survival was 68% at 5 years and 42% after 10 years. Seven patients presented late graft related complications, one fatal. In 14 surviving patients with 21 ureterolysed ureters, one needed a nefrectomy and one a bilateral Boari-plasty. In eight surviving patients with 11 stented ureters, one patient needed a small bowel interposition for ureteral stricture. After CT evaluation, all ureteral stents were removed 3 to 6 months after surgery. CONCLUSIONS: 1. Surgery for IAAA is quite complex. Mortality and morbidity are often associated with emergency or combined vascular and non vascular procedures. 2. When carefull operative repair is performed with minimal dissection of structures from the aneurysmal wall, excellent results can be expected. 3. Ureteral compression should be treated by ureteral stenting, preoperatively, to facilitate ureterolysis or even to avoid it. Regular follow-up CT control is recommended.
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The clinical value of duplex surveillance following internal carotid artery reconstruction.
BACKGROUND: The purpose of this retrospective analysis was to evaluate the benefit of a yearly duplex ultrasonography of both the reconstructed and the contralateral internal carotid artery (ICA). METHODS: From 1985 to 1994, 1210 unilateral, primary ICA reconstructions were performed. Although these patients received yearly invitations, duplex follow-up was not available in 114 patients (9%). RESULTS: At 5 years a stenosis of 50% or more was found in 9% and at 10 years in 14% of patients. During the follow-up period 20 patients developed a stenosis of 80-99%. Ten patients had a redo-procedure. The others remained asymptomatic, even though one patient developed an occlusion. A stroke occurred in 96 patients. 58 of these had no significant stenoses. 57% of all patients had no significant contralateral lesion at the time of the first procedure. In only 4% of these a contralateral CAE was performed during the follow-up. CONCLUSIONS: In view of the above data, we would conclude that the clinical benefit of duplex surveillance is doubtful.
Adult↗
Technique and early results of videoscopic lumbar sympathectomy.
The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.
Adolescent↗
Carotid surgery in octogenarians: is it worthwhile?
Controversy surrounds the role of carotid endarterectomy in octogenarians. Although the prognosis of severe degree carotid stenosis is more ominous in the elderly, operative risk seems more important in the aged. To evaluate the presumed detrimental effect of advanced age on the mortality-morbidity of carotid endarterectomy, the authors reviewed their common experience with carotid surgery in patients aged 80 years or more. From 1980 to 1994, 129 octogenarians were operated on for occlusive carotid artery disease in two university hospitals. The data for these patients, 80 years of age and older (group 1) are compared to these for a large middle age group (less than 80 years) (group 2) operated by the same surgeons during that period. The baseline characteristics of both groups were similar, except for smoking, diabetes and previous myocardial revascularization, more prevalent in the younger age group. In the elderly group prophylactic surgery for asymptomatic stenosis was done in 36%, versus 40% of the middle aged patients, and for stroke in evolution in 8% versus 4% (p < 0.05). The perioperative stroke rate was 0.8% in the group older than 80 years, compared to 1.2% for non octogenarians (NS). The operative mortality was similar for both age groups (2.3 and 1.5 respectively). The long-term results gave a similar outlook for both age groups. The 5-year stroke-free rate reached 89% for group 1 versus 91% for group 2. The 5-year survival rate, however, was less for the elderly patients (47% versus 77%, mean follow-up periods of 30 and 49 months). These results suggest that carotid endarterectomy can be safely done in elderly patients, with a similar risk/benefit ratio as for the younger patients. Advanced age, by itself, is not to be considered as contraindication to carotid surgery.
Adult↗
[Morbidity and mortality after elective surgery of complicated aneurysms].
The post-operative mortality and morbidity after elective surgery of a complicated (difficult) infrarenal abdominal aortic aneurysm are reported. The authors compare a group of 126 patients with a simple uncomplicated aneurysm to a group of 126 patients with a complicated aneurysm. Mortality (3.2%) is similar in both groups but the morbidity is very high in the group of patients with difficult aneurysms. The most frequent complication was renal insufficiency determined by preoperative renal insufficiency. The length of the hospital stay was much longer for the patients after a surgery for a difficult aneurysm. A preoperative correct diagnosis is always possible and the surgical technique varies according the type of anomaly. Even elective surgery of a complicated aneurysm remains a challenge.
Adult↗
Microbiological monitoring of aortic aneurysm sac contents during abdominal aneurysmectomy: results in 176 patients and review of the literature.
To investigate the clinical significance of intraoperative cultures, aneurysmal thrombus was cultured in 176 patients with clinically non suspected infected abdominal aortic aneurysm. The incidence of positive cultures was 14.2% and 88% of the microorganisms were Gram-positive. Differences between elective and urgent reconstruction were not significant. During follow-up, there were no cases of graft infection in either group. Review of the literature shows a positive culture rate of 19% in a series of 1867 patients. 93% Of the microorganisms are Gram-positive and 78% are considered as contaminants. The incidence of graft infection is 1.99% in the group with positive culture and 0.7% in the series with negative culture (P = 0.06). It is concluded that the clinical significance of routine cultures in clinically non suspected infected aortic aneurysms is negligible.
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Early inflammatory response to gelatin- and collagen-sealed Dacron prostheses.
The immediate inflammatory response following aortic reconstruction with two types of sealed Dacron grafts was studied in a prospective, randomized manner. C-reactive protein (CRP) levels were measured before surgery and on days 2 and 8 postoperatively. In the collagen-sealed group (n = 10) CRP levels were 10 +/- 9.6, 180.2 +/- 48.3, and 54.3 +/- 34.3 mg/L, respectively. In the gelatin-impregnated group (n = 10) the values were 10.5 +/- 8.7, 200.7 +/- 27.3, and 80.3 +/- 30.2 mg/L, respectively. The slight differences were not significant according to the analysis of variance test for repeated measurements. These findings suggest that implantation of a knitted Dacron graft sealed with collagen does not lead to a higher inflammatory reaction compared with a gelatin-sealed graft.
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Recurrent aortic infection: treatment by arterial homograft replacement.
Deep infection remains the most problematic complication following prosthetic aortoiliofemoral reconstruction. Prosthetic excision and extra-anatomic revascularization is associated with significant morbidity and mortality. The possibilities of autogenous reconstruction are frequently limited. The authors present a patient with recurrent aortic infection who was successfully treated by prosthetic excision and revascularization in situ with a cryopreserved arterial homograft.
Aneurysm, Infected↗
Autogenous reconstruction with the lower extremity deep veins: an alternative treatment of prosthetic infection after reconstructive surgery for aortoiliac disease.
PURPOSE: This report evaluates the efficiency of use of the lower extremity deep vein as arterial conduits in the autogenous repair of prosthetic infection after reconstructive aortoiliac surgery. METHODS: We reviewed our records for the period 1990 to 1994 of all patients with prosthetic infection after reconstruction for aortoiliac disease, and we selected for this study all those patients who underwent autograft repair with the lower extremity deep veins. RESULTS: Included were 15 patients: 12 had previously undergone direct aorto(ilio)femoral reconstruction, and three had an extraanatomic prosthetic graft. Thirteen patients were admitted with primary graft infection, and two were admitted with secondary graft-enteric erosion. Treatment consisted of prosthetic excision and aorto(ilio)femoral reconstruction with the superficial femoral vein. In situ reconstruction was performed in 12 cases. The operative mortality rate was 7%. There were no early graft occlusions. One patient underwent an above-knee amputation because of concomitant femoropopliteal occlusion in the presence of a patent deep venous aortofemoral graft. Early postoperative limb swelling was common and was controlled with bed rest, elastic stockings, or intermittent pneumatic compression. The mean follow-up of this series was 17 months (range 4 to 33 months). Two patients died of unrelated causes. One graft occluded after 16 months. There were no reinfections, and all but one patient resumed normal daily activities. Disability from removal of the deep veins was minimal: only one patient continues to wear elastic stockings for limb swelling and shows signs of venous hypertension more than 2 years after surgery. CONCLUSION: Harvesting of the lower extremity deep veins is well tolerated. Autogenous reconstruction with these veins provides good potential for salvage of life and limbs in case of prosthetic infection. A longer period of follow-up is required to study the long-term behavior of these grafts and to allow definite comparison with more conventional approaches.
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Lower extremity acute ischaemia due to a metastatic breast fibrosarcoma embolism.
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Aorta, Abdominal↗
Diagnostic value of 99Tcm-d,l-HMPAO-labelled leukocyte scintigraphy in the detection of vascular graft infections.
Prosthetic vascular graft infection is a relatively uncommon complication of peripheral vascular surgery. We retrospectively analysed technetium-99m-d,l-hexamethylpropylene amine oxime (99Tcm-d,l-HMPAO) labelled leukocyte scans of 21 patients with a suspected vascular graft infection. Operative findings, bacteriological cultures, radiological findings or clinical follow-up were used to confirm the diagnosis. We found eight true-positive and six true-negative cases. There were no false-positive scintigraphic diagnoses. The false-negative rate was 33% (n = 7). Our results show a sensitivity of 53%, a specificity of 100% and an accuracy of 66%. The conclusion is that a negative 99Tcm-d,l-HMPAO-labelled leukocyte scan is of limited value in ruling out a vascular graft infection. A combination of computed tomography (CT-scan) and a 99Tcm-d,l-HMPAO-labelled leukocyte scan is probably the most efficient way of diagnosing a vascular graft infection.
Adult↗
Atheromatous embolization precipitated by oral anticoagulants.
Five patients with a "blue or purple" toe syndrome due to atheromatous embolization probably precipitated by oral anticoagulant therapy are reported. In four, the symptoms started a few weeks after initiation of oral anticoagulants and in the fifth they were clearly aggravated by coumarinic drugs. Prior to anticoagulation, one patient had received a course of thrombolytic therapy and two had undergone an arterial catherization without embolic events. A diagnostic arteriography performed in four patients caused no new symptoms. All patients had advanced atherosclerosis. A shaggy aorta and/or pelvic arteries were found in four and in the fifth a highly stenotic femoral lesion appeared the source of peripheral embolization. Oral anticoagulants were interrupted in all five and four underwent reconstructive vascular surgery to eradicate the nidus of atheromatous emboli. One died postoperatively from multiple organ failure. The poor condition of the fifth patient precluded aorto-iliac surgery. No new episodes of embolization occurred and the symptoms disappeared, although one patient needed a toe amputation for a skin lesion that had proceeded to gangrene. The possible role of anticoagulant drugs in precipitating atheromatous embolization is discussed and the importance of recognizing the syndrome is emphasized.
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Local thrombolysis for occluded arterial grafts: is the yield worth the effort?
This study reports the results and complications of local thrombolytic therapy of 50 recently occluded grafts. These occurred in 41 patients with acute severe but still reversible ischemia. The majority were infra-inguinal synthetic grafts. Thrombolysis was induced with urokinase (n = 1), streptokinase (n = 11) or alteplase (n = 38) via an intra-arterial catheter. Complete angiographical lysis was obtained in 36 grafts (72%) and partial lysis in 6 (12%). The highest lysis rate was obtained with alteplase (32/36; 89%). Complementary endovascular and/or surgical intervention was needed in 17 patients to correct an underlying stenosis and/or to save the limb. Fifteen complications occurred (30%) of which distal embolization (n = 4) and bleeding (n = 8 of which 3 fatal) were the most frequent. Six of the bleeding episodes occurred in patients on chronic aspirin intake. The late results were poor. At six months, the primary patency of successfully lysed grafts dropped to 19% and the limb salvage rate to 64%. Thrombolytic therapy is far from the ideal management of thrombosed grafts: maintenance of restored patency is the challenge.
Acute Disease↗
Carotid artery surgery in the presence of an occlusion of the contralateral carotid artery: perioperative risk analysis and follow-up.
A retrospective study of 129 carotid artery reconstructions with an occlusion of the contralateral internal carotid artery (group CO) is presented. A control group comprised 489 patients with a stenosis of < 50% at the contralateral side (group CN). Both groups had the same mean age. There were fewer women in group CO (14% versus 31%, P < 0.0001), and more patients had a history of coronary heart disease (57% versus 44%, P < 0.05). In addition more patients of group CO had suffered a stroke (36% versus 27%, P < 0.05). A temporary shunt was used selectively and more frequently in group CO (87% versus 31%, P < 0.001). Major postoperative complications occurred with equal frequency in both groups: all strokes plus non-cerebral mortality (total combined morbidity and mortality): 4.65% versus 5.5%. The late incidence of stroke was the same in both groups: 8% in CO and 7% in CN at 5 years. The authors conclude that, under the described circumstances and with the appropriate surgical technique, the presence of an occlusion of the contralateral internal carotid artery does not imply an increase in major postoperative complications nor a higher stroke rate during follow-up.
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[Approach to aortic aneurysms including the renal arteries: retroperitoneal method].
A pararenal aneurysm is a rare type of an abdominal aortic aneurysm. The authors report 25 cases out of 429 abdominal aneurysms. The diagnosis was based on a CT-scan and subsequent biplane arteriography. The most common type was the dorsal proximal aortic dilatation, involving the origin of 1 or 2 renal arteries. A retroperitoneal approach was used in 18 of the 25 patients. The most common complication was the retroperitoneal hemorrhage, necessitating reintervention. None of these patients died or developed renal insufficiency despite a suprarenal clamping during the proximal reconstruction.
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The superficial femoral vein as autogenous conduit in the treatment of prosthetic arterial infection.
Autogenous reconstruction is a well-accepted alternative treatment for prosthetic infection after reconstructive arterial surgery. Because of its technical complexity and the lack of suitable substitutes, the procedure remains limited to a few selected centers. We describe four patients with prosthetic infection after reconstructive surgery for lower limb ischemia. Treatment consisted of prosthetic excision and aortofemoral grafting with the use of the superficial femoral vein. All patients survived the operation and infection was eradicated in all cases. We conclude that the superficial femoral vein represents an acceptable arterial conduit in the treatment of these difficult cases.
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