Randomized, multicenter trials of carotid endarterectomy.
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Canada↗
Biomedical subjects
G L Moneta
Publications and source records attributed to G L Moneta.
Surgical treatment of threatened reversed infrainguinal vein grafts.
PURPOSE: Current information concerning the results of surgical revision of threatened infrainguinal vein grafts is largely limited to in situ conduits. Infrainguinal grafts may be threatened by intrinsic graft lesions or significant stenosis in the adjacent inflow or outflow arteries. To assess the results of operative revision of infrainguinal reversed vein grafts, we reviewed our experience with surgical revision of threatened infrainguinal reversed vein grafts identified through a program of postoperative clinical and vascular laboratory graft surveillance. METHODS: All patients who underwent surgical revision of a threatened but patent infrainguinal reversed vein graft from January 1987 through April 1993 were identified through review of our vascular registry. Data were analyzed for type of vein used, date of original reversed vein graft, clinical and vascular laboratory findings leading to reversed vein graft revision, results of preoperative angiography, patient risk factors, operative techniques and complications, and long-term assisted primary graft patency and limb salvage. RESULTS: Ninety-six patients with 100 infrainguinal reversed vein grafts (69) femoral-popliteal, 31 femoral-tibial) underwent 117 surgical vein graft revisions or inflow procedures during the study period. Eighty-one percent of the original reversed vein grafts consisted of a single segment of greater saphenous vein. All revised grafts had at least a 50% stenosis in the graft itself or the proximal or distal artery. A single revision was performed in 85 grafts, two revisions in 13 grafts, and three revisions in two grafts. There were nine (8%) isolated inflow procedures, eight (7%) vein patch angioplasties, 62 (53%) interposition vein grafts, and 29 (25%) vein graft extensions to a new distal anastomotic site. The remaining nine (8%) procedures consisted of combinations of the above. Median time to primary graft revision after initial graft implantation was 15 months (range 2 days to 316 months). Mean time to secondary revision after primary revision was 21 months. Operative mortality was 0.9%. Cumulative assisted primary patency of the original grafts revised for stenotic lesions was 99%, 96%, and 92% at 1, 3, and 5 years, respectively. Limb salvage was 99%, 97%, and 97% at 1, 3, and 5 years, respectively. CONCLUSIONS: Although surgical revision of reversed vein graft requires much use of alternative vein sources, these procedures can be performed with minimum mortality and provide excellent assisted primary graft patency and limb salvage.
Adult↗
Late survival after perioperative myocardial infarction complicating vascular surgery.
PURPOSE: Although early death from perioperative myocardial infarction (PMI) after vascular surgery is well established, long-term outcome in patients surviving PMI is unknown. This prospective study was designed to determine cardiac outcome and survival rates in patients with symptomatic and asymptomatic nonfatal PMI associated with peripheral vascular surgery. METHODS: During a 36-month period for 1989 to 1992, all patients undergoing vascular surgery at our institution were monitored for PMI with serial creatine kinase and myocardial band isoenzymes and electrocardiography. PMIs were classified as symptomatic (associated with chest pain, arrhythmia, congestive heart failure, or hypotension) or asymptomatic (electrocardiographic changes and/or elevated creatine kinase and myocardial band isoenzymes). Patients with PMI were then prospectively monitored and compared for late survival, with control patients undergoing vascular surgery without PMI during the same interval. RESULTS: During the study period 1561 major peripheral vascular procedures were performed. There were 47 PMIs (3.0%). Eleven (0.7%) PMIs were fatal, 31 were nonfatal, and five other patients with PMI died during operation of non-heart-related causes. Eight of 31 patients with nonfatal PMI had a "chemical PMI" with creatine kinase and myocardial band isoenzyme elevation as the sole indicator of PMI. During follow-up (mean 27.7 months), there was a higher incidence of both subsequent myocardial infarction and coronary artery revascularization among the patients with nonfatal PMI compared with control subjects (p < 0.05); however, survival for patients with nonfatal PMI at 1 and 4 years (80% and 51%) did not differ from that of control patients (90% and 60%) (p > 0.05). Patients with "chemical PMI" had similar patterns of subsequent myocardial infarction and coronary intervention as control patients. CONCLUSIONS: Patients surviving nonfatal PMI after peripheral vascular surgery have a higher incidence of subsequent adverse cardiac events and coronary artery revascularization than patients undergoing vascular surgery without PMI, but they have similar survival rates at 1 and 4 years. Patients in the enzyme-only PMI group have a similar outcome compared with control subjects suggesting that a perioperative "chemical MI" may not be a significant clinical event.
Aged↗
Repeat leg bypass after multiple prior bypass failures.
PURPOSE: The optimal treatment of patients with severe lower extremity ischemia after multiple failed prior bypasses is unclear. It is presently unknown whether failure of attempted revascularization in these patients is so likely that such operation should not be elected. We have maintained an aggressive surgical policy of repeated revascularization regardless of prior failures. A review of our clinical experience with this difficult patient group was performed to determine the results of this policy. METHODS: From 1980 to 1992, 85 revascularization procedures were performed in 81 patients with lower extremity ischemia after failure of two or more prior infrainguinal bypasses in the same leg. All patients were prospectively entered and monitored in our vascular registry. Seventy-two operations were the third procedure, six operations were the fourth procedure, and seven operations were the fifth procedure on the same extremity. Twenty-six of the 85 procedures (30%) were revisions of failing grafts discovered by routine surveillance methods, whereas 59 were replacements of thrombosed grafts. Autogenous reconstruction was used in 67 procedures (79%), and prosthetic reconstruction was used in 18 procedures (21%). The distal anastomosis was to the popliteal artery in 19 patients and infrapopliteal artery in 66. RESULTS: Mean time to failure of the first leg bypass was 24 months and 4.9 months for the second bypass. Detailed hematologic screening revealed identifiable hypercoagulable disorders in nine (15%) of 59 patients screened after 1987. All nine had anticardiolipin antibodies. The operative mortality rate was 4%. Mean follow-up after the most recent operation was 17 months. The primary patency rate at 4 years was 79.8%. The limb salvage rate was 69.6% at 4 years. CONCLUSIONS: These results indicate that limb revascularization after two or more failed leg bypasses results in low operative mortality rates and surprisingly good primary patency and limb salvage rates at 4 years. The patient survival rate through 4 years is unexpectedly high. In our opinion these results justify an aggressive policy of limb vascularization after multiple failed prior bypasses.
Adult↗
Hemodynamic assessment of combined aortoiliac/femoropopliteal occlusive disease and selection of single or multilevel revascularization.
Approximately 25% of patients with multilevel arterial occlusive disease will require both inflow and outflow revascularization in order to successfully resolve their symptoms of lower limb ischemia. The preoperative selection of patients for multilevel concurrent arterial reconstruction is guided by symptoms, information from the noninvasive vascular laboratory, the predicted postoperative ABI, and detailed multiview angiography including pull-back intra-arterial pressure measurements. Properly selected patients will benefit from a carefully planned and expeditiously performed simultaneous revascularization. Current results indicate no significant increase in operative morbidity or mortality rates and excellent graft patency rates with these combined procedures.
Aortic Diseases↗
Anticoagulation followed by elective carotid surgery in patients with repetitive transient ischemic attacks and high-grade carotid stenosis.
OBJECTIVE: To evaluate the results of preoperative heparin therapy followed by carotid surgery for patients with repetitive transient ischemic attacks (TIAs) and high-grade carotid stenoses. DESIGN: A 4-year prospective study. SETTING: Oregon Health Science University Hospital and Portland (Ore) Veterans Affairs Hospital. PATIENTS: Twenty-nine consecutive patients with repetitive TIAs referable to 30 high-grade (> or = 70%) ipsilateral carotid stenoses were treated with short-term heparin anticoagulation, followed by cerebral angiography, routine preoperative evaluation, and subsequent carotid reconstruction. INTERVENTIONS: Heparin sodium anticoagulation was maintained for a mean of 5 days. Surgical management consisted of 24 standard endarterectomies, five bypasses to the internal carotid artery, and one external carotid endarterectomy. MAIN OUTCOME MEASURES: Primary outcome variables included perioperative hemorrhage, thrombocytopenia, stroke, and death. Secondary outcome variables included carotid occlusion and recurrent TIAs with heparin therapy. RESULTS: One symptomatic common carotid occlusion and one asymptomatic internal carotid occlusion occurred during preoperative heparin therapy. Thirteen patients had additional sporadic TIAs while receiving heparin. There were no preoperative cerebral infarcts, thrombocytopenia, or clinical bleeding associated with heparin therapy. There was one postoperative stroke and one death due to myocardial infarction. CONCLUSION: When necessary, heparin anticoagulation and delayed carotid reconstruction would appear to be an acceptable alternative to emergency carotid surgery in patients with high-grade carotid stenosis and acute repetitive TIAs.
Aged↗
Noninvasive localization of arterial occlusive disease: a comparison of segmental Doppler pressures and arterial duplex mapping.
PURPOSE: The purpose of this study was to compare the abilities of arterial duplex mapping and segmental Doppler pressures to noninvasively localize hemodynamically significant lower extremity arterial occlusive disease. METHODS: After angiographic controls were instituted, arterial duplex mapping and segmental Doppler pressures were blindly compared for their ability to localize a high-grade (50% to 100%) stenosis to the iliac or common femoral arteries, the superficial femoral artery, or the popliteal artery in 151 lower extremities from 79 patients. RESULTS: Rates of sensitivity and specificity of arterial duplex mapping for identifying a high-grade stenosis at the three arterial levels were 88% and 97%, 95% and 100%, and 78% and 99%, respectively. Those for segmental Doppler pressures were 59% and 86%, 73% and 80%, and 48% and 53%, respectively. There was complete agreement between arterial duplex mapping and angiography in 82% of the limbs studied and between segmental pressures and angiography in 34% of the limbs (p < 0.0001). The presence of diabetes, kidney failure, or previous vascular surgery in the limb studied did not affect the accuracy of either test. CONCLUSION: Arterial duplex mapping is far superior to segmental Doppler pressures for localization of high-grade angiographic lesions from the iliac to the popliteal arteries.
Aged↗
Mesenteric duplex scanning: a blinded prospective study.
PURPOSE: Based on retrospective comparisons of duplex scanning with arteriography of the celiac (CA) and superior mesenteric (SMA) arteries in 34 patients, we previously suggested that an SMA peak systolic velocity of 275 cm/sec or greater or no flow signal and a CA PSV of 200 cm/sec or greater or no flow signal were reliable indicators of a 70% or greater angiographic stenosis of the SMA and CA, respectively. We now report the results of a blinded, prospective study in a larger patient group designed to determine the ability of mesenteric duplex scanning to visualize the CA and SMA and to validate our proposed duplex criteria for splanchnic artery stenosis. METHODS: During an 18-month period 100 patients admitted to our vascular surgery service for aortography underwent routine mesenteric artery duplex scanning and lateral abdominal aortography regardless of abdominal symptoms. The lateral aortograms were evaluated to determine the presence or absence of a 70% or greater stenosis in the CA or SMA. Duplex-determined peak systolic velocities from the CA and SMA were recorded without knowledge of the angiographic results. RESULTS: Aortography satisfactorily visualized 100% of the CAs and 99% of the SMAs. Of these, 93% of the SMAs and 83% of the CAs were visualized by duplex. According to the above criteria, duplex sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for detection of a 70% or greater SMA stenosis were 92%, 96%, 80%, 99%, and 96% and for a 70% or greater CA stenosis 87%, 80%, 63%, 94%, and 82%. CONCLUSIONS: Mesenteric duplex scanning is feasible in the majority of patients. Prospective evaluation of duplex diagnostic criteria for 70% or greater stenosis indicates that mesenteric duplex scanning is sufficiently accurate to be clinically useful as a screening examination to detect SMA and CA stenosis.
Adult↗
Human saphenous vein grafts explanted from the arterial circulation demonstrate altered smooth-muscle and endothelial responses.
PURPOSE: Animal models have been used to assess the function of vascular smooth muscle and endothelium of veins grafted into arterial circulation. The primary model consists of grafting the external jugular vein into the carotid artery of the rabbit. These studies suggest a selective increase in the responsiveness of the grafted veins to serotonin. However, in both human cardiac and peripheral vascular operations, the saphenous, not the jugular, is the vein most frequently used. Thus the propriety of the rabbit model is unknown. METHODS: Human saphenous veins and vein grafts were obtained from patients undergoing leg vein bypass graft revisions (n = 8). The reversed vein grafts were placed into arterial circulation for periods ranging from 4 to 26 months before removal (mean 16 months). All vessels were immediately cut into rings and suspended in organ chambers for recording isometric contractions to norepinephrine and serotonin. RESULTS: The maximal contractions elicited by both norepinephrine and serotonin were reduced in human vein grafts in comparison to the results in human saphenous vein (maximal response to norepinephrine 1.42 +/- 0.34 gm [vein graft] vs 4.59 +/- 1.13 gm [saphenous vein], p = 0.031; maximal response to serotonin 2.68 +/- 0.58 gm [vein graft] vs 4.72 +/- 1.11 gm [saphenous vein], p = 0.042). Human vein grafts were less responsive to norepinephrine than was saphenous vein (negative log of concentration that caused 50% of the maximal response -5.91 +/- 0.10 and -6.84 +/- 0.22, respectively; p < 0.009). After precontraction with norepinephrine (to 30% of the maximal response), saphenous vein, but not vein grafts, demonstrated endothelium-dependent relaxation to acetylcholine (maximum relaxation 27.4% +/- 6.8%; p = 0.001). CONCLUSIONS: Human saphenous veins grafted into arterial circulation exhibit loss of endothelium-dependent relaxation to acetylcholine and diminished contractions to agonists (norepinephrine and serotonin). In contrast to rabbit data, serotonin elicits dose-dependent contractions in both human saphenous vein and human vein grafts. Since the vascular wall contractility varies widely across species, the relevance of rabbit vein graft data to human bypass grafts is uncertain.
Acetylcholine↗
Correlation of North American Symptomatic Carotid Endarterectomy Trial (NASCET) angiographic definition of 70% to 99% internal carotid artery stenosis with duplex scanning.
PURPOSE: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has thus far demonstrated conclusive benefit for carotid endarterectomy for patients with symptomatic 70% to 99% internal carotid artery (ICA) stenosis. In the NASCET, ICA stenosis was classified angiographically: % ICA stenosis = (1 - [narrowest ICA diameter/diameter normal distal cervical ICA]) x 100%. However, widely used duplex scan criteria for ICA stenosis correlate with different angiographic categories of high-grade stenosis (50% to 79%, > 80%) and were developed on the basis of estimated bulb diameter. We therefore blindly evaluated with separate observers carotid angiograms from 100 patients who also underwent carotid duplex scanning in our vascular laboratory. METHODS: "Angiographic stenosis" was calculated as in NASCET. Duplex scan measurements of ICA peak systolic velocity (PSV), ICA end-diastolic velocity, and the ratio of ICA PSV to common carotid artery (CCA) PSV were analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy to identify a 70% to 99% ICA stenosis. RESULTS: Analysis of the data revealed that an ICA PSV/CCA PSV ratio of 4.0 provided the best combination of sensitivity (91%), specificity (87%), positive predictive value (76%), negative predictive value (96%), and overall accuracy (88%) for detection of a 70% to 99% stenosis. CONCLUSION: We conclude duplex scan determination of 70% to 99% stenosis as defined in the NASCET requires the adoption of duplex criteria modified from those in current use in most vascular laboratories.
Angiography, Digital Subtraction↗
Outcome of infrainguinal arterial reconstruction in women.
PURPOSE: The outcome of leg bypass in women is unknown. To date, most series of lower extremity bypass have included few women, and the results in women compared with those in men have not been reported. The experience with infrainguinal arterial reconstruction in women treated at the Oregon Health Sciences University has been greater than previously reported. We have reviewed our recent experience with lower extremity bypass to determine whether results in women differ significantly from those in men. METHODS: In the past 11 years we have performed 823 infrainguinal arterial reconstructions for lower extremity ischemia in 585 patients, of which 357 procedures were performed in women and 466 procedures were performed in men. The mean ages were 65 years for men and 68 years for women. Diabetes was present in 59% of the men and 48% of the women. Among men, 84% had a history of tobacco use compared with 66% of the women. Bypasses in men were performed for limb salvage in 73%, claudication in 22%, and a failing bypass graft in 5% of cases. Bypasses in women were performed for limb salvage in 79%, claudication in 15%, and a failing graft in 6% of cases. Previous revascularizations had been performed in 63% of the men and 71% of the women. Autogenous vein was used in 97% of the bypasses in men and 96% of bypasses in women. Graft distribution among infrainguinal arterial target sites was similar between the groups. Bypasses in men were femoral to above-knee popliteal in 11%, femoral to below-knee popliteal in 40%, femoral to tibial in 38%, popliteal to tibial in 10%, and tibial to tibial in 1% of cases. Bypasses in women were femoral to above-knee popliteal in 14%, femoral to below-knee popliteal in 43%, femoral to tibial in 33%, popliteal to tibial in 9%, and tibial to tibial in 1% of cases. RESULTS: Perioperative 30-day mortality rates were 3.7% overall, 4.3% in men, and 2.9% in women. Long-term survival at 1, 3, and 5 years in men was 80%, 59%, and 44%, respectively. Long-term survival at 1, 3, and 5 years in women was 83%, 69%, and 44%, respectively. Life-table primary patency rates at 1, 3, and 5 years were 86%, 77%, and 71% for men and 87%, 74%, and 67% for women. Limb-salvage results at 1 and 5 years were 93% and 91% for men and 96% and 96% for women. CONCLUSIONS: These results indicate that long-term graft patency and limb salvage results in women are identical to those obtained in men in this experience with autogenous vein. Infrainguinal arterial reconstruction can be performed in women with mortality rates similar to those of men. In this series long-term survival was similar for both men and women.
Adolescent↗
Perimalleolar subcutaneous tissue pressure effects of elastic compression stockings.
PURPOSE: We hypothesized that the clinical benefit of elastic compression stockings (ECS) is at least in part due to an increase in subcutaneous pressure that may promote resorption of extracellular fluids, providing more efficient diffusion of oxygen and nutrients from the microcirculation to the skin and subcutaneous tissues. METHODS: To test this hypothesis we designed and standardized a device for measuring subcutaneous pressure in patients. We then measured the supine perimalleolar subcutaneous pressure from a single limb in four groups: group 1 consisted of control subjects (n = 8); group 2 consisted of patients with varicose veins and superficial venous insufficiency without lipodermatosclerosis or edema (n = 5); group 3 consisted of patients with deep venous insufficiency and lipodermatosclerosis but without edema (n = 8); and group 4 consisted of patients with deep venous insufficiency, lipodermatosclerosis, and clinically evident edema (n = 8). Measurements were made at baseline and after application of 20 to 30 mm Hg and 30 to 40 mm Hg ECS. RESULTS: There was no significant difference in the baseline subcutaneous pressure between the three groups without clinical edema (p > 0.05). Baseline perimalleolar pressure was elevated, however, in group 4 patients compared with groups 1, 2, and 3 (p < 0.05). All three groups with chronic venous insufficiency (CVI) (groups 2, 3, 4) demonstrated increases in subcutaneous pressure with application of ECS, which was statistically significant in groups 3 and 4. There was no difference between the increase in perimalleolar subcutaneous pressure induced by 20 to 30 mm Hg or 30 to 40 mm Hg ECS in groups 3 and 4. CONCLUSIONS: Patients with CVI and edema have significant elevations in supine resting perimalleolar subcutaneous pressure compared with control subjects and patients with CVI without edema. Twenty to 30 mm Hg and 30 to 40 mm Hg ECS increased measured perimalleolar subcutaneous pressure in patients with CVI with and without clinical edema but not in control patients. These results suggest the mechanism of benefit of ECS in patients with CVI is due at least in part to an increase in subcutaneous pressure that may act to promote more efficient absorption of perimalleolar extracellular fluid.
Adult↗
Repair and follow-up of leg arteries with vein grafts.
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Graft Occlusion, Vascular↗
Surgery for chronic lower extremity ischemia in patients eighty or more years of age: operative results and assessment of postoperative independence.
PURPOSE: Revascularization for chronic lower extremity ischemia (CLEI) in patients 80 or more years of age is controversial. High operative mortality, short remaining life span, and nonambulatory nursing home existence are cited as frequent outcomes in this patient group. Despite these considerations we have maintained an aggressive policy of lower extremity revascularization in functional and potentially functional patients 80 or more years of age with limb-threatening ischemia or claudication sufficient to threaten their independence. METHODS: The records of all patients 80 or more years of age who underwent lower extremity revascularization for CLEI from 1981 through 1991 were reviewed. Patients were evaluated for surgical indication, perioperative mortality, late survival, graft patency, and limb salvage. In addition, the patient's preoperative and postoperative independence determined by living situation (home versus nursing home) and ambulatory status were examined. RESULTS: During the period reviewed 88 patients 80 or more years of age underwent 95 arterial reconstructions for CLEI; 95% for limb salvage and 5% for short-distance claudication. There were 81 (85%) infrainguinal bypasses and 14 (15%) extra-anatomic bypasses, 5 of which also included a simultaneously placed infrainguinal bypass. The perioperative mortality rate was 6%. Mean hospitalization was 18 days (range 6 to 62). The 1- and 3-year primary graft patency rates were 88% and 66%, limb salvage rates 94% and 91%, and patient survival rates 73% and 51%, respectively. One year after operation 88% of patients were ambulatory, 85% were living at home, and 80% were both living at home and ambulatory. At 3 years these results were 86%, 76%, and 71%, respectively. Of the patients living at home and ambulatory before operation, 100% and 84% of survivors were still living at home and ambulatory 1 and 3 years after operation. Of patients living at home who had late graft occlusions, 67% required amputation and subsequent nursing home placement. CONCLUSION: Although survival in this group is predictably lower than that of age-matched control subjects, octogenarians have satisfactory 1- and 3-year graft patency, limb salvage, and functional results. Revascularization for CLEI in patients 80 or more years of age is appropriate and results in maintenance of independent living in a large majority.
Activities of Daily Living↗
Extra-anatomic bypass: a new look (supporting view).
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Aorta, Abdominal↗
Neurologic deficits following noncarotid vascular surgery.
Neurologic events following noncarotid vascular surgery (NCVS) are considered unpredictable. To test this hypothesis, we reviewed our vascular registry for a 3-year period and identified all patients with new postoperative focal neurologic events (stroke, hemispheric transient ischemic attack [TIA]) within 2 weeks of a category I or II vascular procedure as defined by the American Board of Surgery, exclusive of carotid surgery and arterial trauma. Thirteen of 1,390 NCVS procedures (0.9%) in 13 patients were associated with focal neurologic events. There were 2 TIAs, 10 anterior circulation strokes, and 1 posterior circulation stroke. Twenty-seven percent of strokes were fatal. The neurologic deficit developed in the immediate postoperative period in 31%, more than 4 hours but less than 72 hours postoperatively in 54%, and within 3 to 14 days postoperatively in 15%. Patients with anterior circulation events (group A, n = 12) were compared for variables potentially influencing postoperative stroke with case controls who were selected using a table of random numbers (group B, n = 12). Controls were derived from a pool of all category I or II NCVS procedures recorded in our vascular registry sequentially during the same time period and who were without new neurologic deficits postoperatively. Using Fisher's exact test, comparisons between groups A and B revealed that new anterior circulation neurologic events in vascular surgical patients tended to be associated with intra-abdominal procedures (p less than 0.05), perioperative hypotension (p less than 0.05), and the presence of a greater than or equal to 50% internal carotid artery stenosis ipsilateral to the neurologic event (p less than 0.001). Such information may prove useful in the management of selected patients prior to arterial reconstruction and in operated NCVS patients with postoperative neurologic events.
Aged↗
The incidence of perioperative myocardial infarction in general vascular surgery.
In a 1-year period all patients undergoing general vascular surgery (491 patients, 534 procedures) underwent monitoring by creatine phosphokinase isoenzymes and electrocardiograms (ECG) to detect perioperative myocardial infarction. Only those patients with severe symptomatic coronary artery disease (31 patients, 5.8%) characterized by unstable angina pectoris, uncontrolled arrhythmia, or severe congestive heart failure had any testing for coronary artery disease beyond history, physical examination, and ECG. Only three patients (0.5%) had prophylactic coronary artery bypass performed before general vascular procedures. Twenty-one (3.9%) myocardial infarctions (five asymptomatic, detected by enzymes only, and 16 symptomatic, four of which were fatal) were associated with the 534 procedures (aorta 105, carotid 87, infrainguinal bypass 207, extraanatomic 51, other 84). Eight noncardiac perioperative deaths occurred. All operative deaths (12 of 534, 2.2%) including all four fatal myocardial infarctions occurred associated with surgery on an urgent or emergency basis (12 of 249 procedures, urgent/emergent operative mortality rate 4.8%). No operative deaths and no fatal myocardial infarctions associated with the 285 elective procedures occurred. Nine of the 17 nonfatal myocardial infarctions (53%) also occurred after urgent/emergent procedures. The rate of perioperative myocardial infarctions (eight of 285, 2.8%) after elective surgery in this patient series is no different from that reported by multiple recent authors advocating widespread screening for and prophylactic treatment of coronary artery disease before general vascular surgery. Our experience confirms the therapeutic approach that expensive and invasive coronary screening programs in patients to undergo vascular operations should be limited to carefully selected patients with severely symptomatic coronary disease.
Adult↗
Surgical management of severe acute lower extremity ischemia.
Seventy-four patients (70 men [95%], 4 women [5%], mean age, 63 years) with severe, acute lower limb ischemia (acute clinical deterioration and absent pedal Doppler signals) caused by either arterial thrombosis (n = 68) or embolism (n = 6) underwent urgent surgical management consisting of operative revascularization with or without amputation in 67 patients (91%) and primary amputation alone in 7 patients (9%). Sixty-one patients (82%) had severely threatened limb viability, and 13 (18%) had major irreversible ischemic limb changes at presentation. Eighty-six percent of patients were initially anticoagulated with heparin. Seventy percent underwent preoperative angiography. Surgical revascularization included 42 inflow and 20 outflow arterial reconstructions and 9 thrombectomy or embolectomy procedures. Mean follow-up was 17 months (range, 0 to 64). Life-table primary patency at 36 months for arterial reconstructions was 81% for inflow and 78% for outflow procedures. Cumulative limb salvage was 70% at 1 month and 68% at 36 months. Patient survival was 85% at 1 month and 51% at 36 months. No death was directly attributable to complications related to limb reperfusion, and no patient required dialysis for myoglobinuria. We conclude that management of severe, acute lower limb ischemia with early amputation of nonviable limbs and heparinization, angiography, and prompt operative revascularization for threatened but viable extremities minimizes morbidity and mortality rates, while maximizing limb salvage. These results may be useful for comparison with comparable groups of patients treated with thrombolytic or endovascular modalities.
Acute Disease↗