Maintenance of patency following remote superficial femoral artery endarterectomy

BACKGROUND: Remote superficial femoral artery endarterectomy (RSFE) is a minimally invasive means of superficial femoral artery revascularisation. It comprises a single groin incision and securing of the distal cut end of atheroma with an intraluminal stent. AIM: To determine medium-term results of RSFE, with particular reference to costs of maintaining patency. METHODS: Stenosis development, and patency of 25 RSFE were compared with 25 randomly selected in situ vein bypasses with similar follow-up (18-33 months). RESULTS: Following RSFE 17 stenoses were identified by duplex surveillance. Half of those arteries patent at 1 yr had stenoses. Angioplasty (PTA) was carried out for 11 stenoses. Four stenoses developed more than 12 months following RSFE. One patient died and nine arteries occluded during follow-up. Primary and primary- assisted patency at 18 months were 31 and 63% respectively. By contrast six stenoses were identified in 25 in situ grafts, all within one year. Four PTAs were carried out. Three grafts occluded. Excluding cost of three monthly duplex surveillance the cost of maintaining RSFE patency was approximately five times that of maintaining in situ bypass patency. CONCLUSION: The initial cost advantage of RSFE is offset by the increased costs of maintaining patency. Duplex surveillance probably needs to be continued indefinitely.     

Early results of external iliac artery stenting combined with common femoral artery endarterectomy

PURPOSE: The endovascular approach to external iliac artery (EIA) disease extending into the common femoral artery (CFA) has been avoided because of problems with stent placement across the inguinal ligament. Surgical treatment for this disease distribution includes extensive endarterectomy or bypass procedures or both. We report our initial experience with a combined open and endovascular approach to these patients. METHODS: We performed a retrospective analysis of all patients who underwent intraoperative EIA stenting after CFA endarterectomy/patch angioplasty between 1997 and 2000. Stents were positioned to end at the proximal endarterectomy endpoint, without crossing the inguinal ligament. Technical success, hemodynamic success, and clinical success were determined according to Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria. Life-table analysis was performed for patency. RESULTS: Thirty-four patients (mean age, 68 years; 23 male, 11 female) had combined endovascular and open treatment of iliofemoral occlusive disease. Indications were claudication in 41% and critical limb ischemia in 59%. Femoral reconstruction included endarterectomy with patch angioplasty in all patients. EIA stent deployment incorporated the stenotic iliac segment and the proximal endpoint of the endarterectomy in all patients. Four patients (12%) also needed common iliac angioplasty at the same time for proximal iliac disease, and 14 patients (41%) also needed distal revascularization for associated femoropopliteal or tibial disease. Technical success and hemodynamic success were achieved in 100% of patients. Clinical success was achieved in 97% of patients. The mean postoperative increase in ankle-brachial index in patients with inflow procedures only was 0.36 (range, 0.1 to 0.85). The overall complication rate was 15%. With a mean follow-up period of 13 months (range, 0.5 to 28 months), 1-year primary patency and primary-assisted patency rates were 84% and 97%, respectively. No perioperative mortality was seen. CONCLUSION: EIA stenting as an adjunct to CFA endarterectomy/patch angioplasty allows for more localized surgery than conventional bypass. This approach also allows a better interface between the stent and endarterectomy than staged preoperative stenting. Technical success and early patency rates are excellent.     

Risk factors for perioperative myocardial ischemia in carotid artery endarterectomy

OBJECTIVE: To identify variables associated with perioperative myocardial ischemia in patients undergoing carotid artery endarterectomy (CEA). DESIGN: Prospective, observational study. SETTING: University-affiliated hospital operating room and intensive care unit. PARTICIPANTS: One hundred twenty-eight consecutive patients who underwent CEA during a 7-year period. INTERVENTIONS: Patients had general anesthesia with sevoflurane or isoflurane. CEA was performed by standard methods with shunting if clinically indicated. Holter electrocardiogram (ECG) monitoring was performed during surgery and 24 hours after surgery. MEASUREMENTS AND MAIN RESULTS: The incidence of perioperative myocardial ischemia was examined, and perioperative risk factors were analyzed. Nineteen patients (15%) showed significant perioperative ECG abnormalities indicative of myocardial ischemia (10 patients during surgery, 12 patients after surgery, and 3 patients both during and after surgery). Multivariate analysis showed perioperative myocardial ischemia to be significantly associated with a history of angina (odds ratio, 11.68; 95% confidence interval, 2.64-51.70) and a history of hypertension (odds ratio, 14.08; 95% confidence interval, 1.51-131.04). CONCLUSION: The data indicate that perioperative myocardial ischemia defined as an ECG abnormality does not often occur in patients undergoing CEA. However, angina and hypertension may be important risk factors warranting further investigation.     

Remote superficial femoral artery endarterectomy

Remote superficial femoral artery endarterectomy (RSFAE) is an effective minimal invasive treatment modality of TransAtlantic Inter-Society Consensus (TASC) C and D atherosclerotic lesions of the superficial femoral artery (SFA) with at least equal patency rates as supragenicular synthetic bypass grafts. This procedure is performed through a single femoral arteriotomy and the intima core in the SFA is dissected using the Vollmar ring and the Mollring cutter devices, respectively. The intimal core distally of the transaction zone is secured by an expandable polytetrafluoroethylene-covered nitinol stent. By its minimal invasive character, RSFAE will lead to lower rate of postoperative complications and shorter hospital stay compared to supragenicular bypass graft surgery. Additional advantage in comparison with percutaneous procedures is the opportunity of open endarterectomy of the common femoral and/or profunda artery. Synthetic material will be avoided and vein will be preserved for possible future cardiovascular surgery. Reobstruction of the SFA tends to have, in contrast to bypass grafts, less severe symptoms due to preservation of collaterals and thereby lower amputation rate. Achilles heel of RSFAE is the relatively high percentage of first year restenosis due to neointimal hyperplasia. Strict follow-up at 3, 6 and 12 months is advised including duplex ultrasound. In case of symptomatic or asymptomatic hemodynamic restenosis (>50%) percutaneous transluminal angioplasty must be performed to improve long-term patency. The majority of reobstructions can be treated by endovascular means. New endovascular techniques, like balloon cryoplasty or drug eluting stents have to be studied in combination with RSFAE to optimize its technique and improve patency rates.     

Remote superficial femoral artery endarterectomy

The advent of minimally invasive procedures such as percutaneous transluminal angioplasty with or without stent, laser-assisted balloon angioplasty, and atherectomy, whose results have proven disappointing in the treatment of long-segment (> more than 15 cm) superficial femoral artery (SFA) occlusive disease, stimulated a reassessment of SFA endarterectomy. With the evolution of remote superficial femoral artery endarterectomy (RSFAE) a minimally invasive technique became available which could be performed through a single incision, allowed, debulking of the arterial plaque, and placement of an endovascular stent. We report results of RSFAE in an initial trial, results of RSFAE in concert with the aSpire Covered Stent which is a flexible ePTFE covered Nitinol stent with significant radial strength to withstand torsional stresses at the knee joint, and RSFAE and distal vein bypass for limb salvage.     

Risk factors for surgical wound infection and bacteraemia following coronary artery bypass surgery

BACKGROUND: There has been no consensus from previous studies of risk factors for surgical wound infections (SWI) and postoperative bacteraemia for patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: Data on 15 potential risk factors were prospectively collected on all patients undergoing CABG surgery during a 12-month period. RESULTS: Of 693 patients, 62 developed 65 SWI using the Centres for Disease Control definition: 23 were sternal wound infections and 42 were arm or leg wound infections at the site of conduit harvest. There were 19 episodes of postoperative bacteraemia. Multivariate analysis revealed that: (i) diabetes, obesity and previous cardiovascular procedure were independent predictors of SWI; and (ii) obesity was an independent risk factor for postoperative bacteraemia. CONCLUSIONS: These findings suggest that improved diabetic control and pre-operative weight reduction may result in a decrease in the incidence of SWI. But further prospective studies need to be undertaken to examine (i) whether the increased SWI risk in diabetes occurs with both insulin- and non-insulin-requiring diabetes, and whether improved peri-operative diabetes control decreases SWI; and (ii) what degree of obesity confers a risk of SWI and postoperative bacteraemia, and whether pre-operative weight reduction, if a realistic strategy in this patient group, results in a decrease in SWI.     

Outcome of drug-eluting balloon angioplasty versus endarterectomy in common femoral artery occlusive disease

Objective

Common femoral artery (CFA) occlusive disease remains a debatable site for endovascular therapy, and the outcome of drug-eluting balloon (DEB) angioplasty in treating CFA occlusive disease is largely unknown. This study compared the efficacy, safety, and short-term patency rate of DEB angioplasty and femoral endarterectomy for treatment of CFA occlusive disease.

Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery

Objective: To identify risk factors for sternal wound infection following coronary artery bypass surgery (CABG), and to compare early and mid-term survival outcome. Methods: Data were prospectively collected for 4228 patients who underwent CABG surgery between April 1997 and March 2001. One hundred and nine (2.6%) patients developed sternal wound infection. We used logistic regression to identify independent risk factors associated with post-operative sternal wound infection. Patient records were linked to the National Strategic Tracing Service, which records all deaths in the UK, to establish current vital status. Deaths occurring over time were described using Kaplan–Meier techniques. To control for differences in patient characteristics, we used Cox proportional hazards analysis to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI). Results: The results of the logistic regression analysis found that the independent predictors of sternal wound infection were obesity (odds ratio (OR) 2.0; P<0.001), New York Heart Association class ≥3 (OR 1.6; P=0.022), use of bilateral internal mammary arteries (OR 3.2; P<0.001), increasing number of grafts (OR 1.5; P<0.001), re-exploration for bleeding (OR 3.1; P=0.011), and increased duration of mechanical ventilation (for every 10 h (OR 1.12; P<0.001)). Three hundred and forty one (8.1%) deaths occurred during the study period with mean follow up of 3.2±1.3 years. The crude HR of mid-term mortality for sternal wound infection patients was 2.51 (95% CI 1.59–3.94, P<0.001). After adjustment for pre, intra and post-operative factors, the adjusted HR of mid-term mortality for sternal wound infection patients was 1.64 (95% CI 1.03–2.61, P=0.037). The adjusted freedom from death for sternal wound infections at 30 days, and 1, 2 and 4 years was 96.8, 93.7, 91.4 and 86.7%, respectively, compared with 98.1, 96.1, 94.7 and 91.7% for patients without sternal wound infections. Conclusions: In conclusion, we have identified risk factors for sternal wound infection, many of which are modifiable. We have also shown that there is a significant increase in mortality in patients with sternal wound infection during a 4-year follow-up period after CABG.     

Risk factors for stroke following coronary artery bypass operations

BACKGROUND: Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8-year period in our clinic. METHODS: Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. RESULTS: Mean age of these patients was 62.3 +/- 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty-seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. CONCLUSION: Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.     

Risk factors for postcarotid endarterectomy hematoma formation

PURPOSE: To identify risk factors for post-carotid endarterectomy (CEA) hematoma formation and establish the incidence of this complication at The Ottawa Hospital - Civic Campus (TOH-CC). METHODS: A chart review of all patients who underwent CEA at TOH-CC from January 1, 1996 to December 31, 1997 was completed. Identified cases of post-CEA wound hematoma were entered into a case-control study using age and sex-matched controls from within the cohort. These matched pairs were assessed for 31 potential risk factors including demographic details, co-existing medical conditions, preoperative medications, intraoperative management, and postoperative parameters. Risk factors associated with post-CEA hematoma with P<0.05 were entered into a backward step-wise logistic regression model for multivariate analysis. RESULTS: Charts from 249 patients were reviewed and 29 cases of post-carotid endarterectomy hematoma were identified (12% incidence). Six of the initial 31 potential risk factors emerged as univariate predictors of post-CEA hematoma formation (P<0.05): general anesthesia, carotid shunt placement, intraoperative hypotension, non-reversal of heparin, neurosurgery service, and preoperative aspirin use. Following logistic regression only non-reversal of heparin, intraoperative hypotension, and carotid shunt placement were identified as multivariate predictors of post-CEA hematoma formation. More time was spent in critical care settings (ICU/PACU) (P<0.01) and there was increased perioperative mortality (P = 0.04) within the hematoma group. CONCLUSIONS: Post-CEA hematoma formation is associated with increased morbidity and mortality. Non-reversal of heparin, intraoperative hypotension, and carotid shunt placement are multi-variate predictors of post-CEA hematoma formation.     

髂动脉支架联合股动脉内膜剥脱术治疗多节段髂股动脉闭塞症

目的 探讨多节段髂股动脉闭塞症的治疗手段及临床疗效.方法 选择2008年1月2011年6月间采用髂动脉支架植入联合股动脉内膜剥脱+补片成形术治疗的多节段髂股动脉硬化闭塞症36例患者,其中男性26例,女性10例;年龄49～ 87岁,平均65岁.对患者的随访结果进行回顾性分析,评价术前、后患者临床症状改善情况,采用Kaplan-Meier生存分析比较不同Fontaine分级患者间一期通畅率的差异,采用Cox回归分析筛选影响一期通畅率的独立因素等.结果 本组患者手术均获成功,术后34例(94.4％)临床症状得到明显改善.平均随访24.2个月,一期通畅率为72.2％,辅助一期通畅率为83.3％,二期通畅率为94.4％.生存分析显示FontaineⅡ级患者一期通畅率明显高于Ⅲ、Ⅳ级患者(P =0.041、0.012).Cox回归分析未发现影响术后一期通畅率的独立因素.结论 髂动脉支架植入联合股动脉内膜剥脱+补片成形术是治疗多节段髂股动脉闭塞症的有效方法,随访结果良好.     

Risk factors for urinary tract infection following incontinence surgery

Introduction and hypothesis

The purpose of this study is to describe risk factors for post-operative urinary tract infection (UTI) the first year after stress urinary incontinence surgery.

Methods

Multivariable logistic regression analyses were performed on data from 1,252 women randomized in two surgical trials, Stress Incontinence Surgical Treatment Efficacy trial (SISTEr) and Trial Of Mid-Urethral Slings (TOMUS).

Results

Baseline recurrent UTI (rUTI; ??3 in 12?months) increased the risk of UTI in the first 6?weeks in both study populations, as did sling procedure and self-catheterization in SISTEr, and bladder perforation in TOMUS. Baseline rUTI, UTI in the first 6?weeks, and PVR?>?100?cc at 12?months were independent risk factors for UTI between 6?weeks and 12?months in the SISTEr population. Few (2.3?C2.4%) had post-operative rUTI, precluding multivariable analysis. In women with pre-operative rUTI, successful surgery (negative cough stress test) at 1?year did not appear to decrease the risk of persistent rUTI.

Conclusions

Pre-operative rUTI is the strongest risk factor for post-operative UTI.     

Carotid artery angioplasty for restenosis following endarterectomy.

INTRODUCTION: The higher complication rate associated with the surgical treatment of restenosis following carotid endarterectomy (CEA) has led several authors to advocate angioplasty as the treatment of choice in the management of restenosis. We describe our experience with internal carotid artery angioplasty for post-endarterectomy restenosis over 7 years. PATIENTS AND METHODS: From January 1994 to April 2001, all patients with a >90% restenosis following CEA were considered for angioplasty. Thirty angioplasties were carried out in 25 patients, 80% (24/30), for asymptomatic recurrent stenosis. There was no difference between those who had intervention for recurrent stenosis (n=31) and those who did not (n=545) in age, sex, smoking status or incidence of diabetes or hypertension. A significantly greater number of patients who underwent angioplasty were hypercholesterolaemic (p<0.05, Chi-squared test). RESULTS: Mean time from surgery to angioplasty was 13 months (range 1-23). Angioplasty was technically successful in 29 cases (97%). Three patients (10%) experienced transient neurological symptoms during the procedure. There were no strokes. Ninety-six percent (28/29) of patients were followed up with duplex scanning. Mean follow-up was 20 months (range 2-48). Three patients developed a greater than 90% restenosis. CONCLUSION: Angioplasty is an acceptable alternative to surgery in the management of internal carotid artery restenosis following endarterectomy.     

Noninvasive carotid artery evaluation following endarterectomy

There has been recent interest in carotid restenosis following endarterectomy. To evaluate the significance of this complication, 2549 consecutive patients who were evaluated for suspected carotid artery occlusive disease by carotid phonoangiography, ocular plethysmography, and B-mode scanning techniques over a 21-month period were reviewed. Within this group a total of 155 patients had previously undergone a carotid endarterectomy. Of these, only four patients manifested clinically significant restenosis. In the majority of patients the carotid bifurcation was free of significant disease. The “carotid shelf” that represents the superior aspect of residual intimal plaque following endarterectomy could be clearly identified in the early postoperative period; however, it later blended to become less distinct. In a few instances, however, the amount of residual plaque at the lower extent of the endarterectomy was very prominent and remained so during follow-up studies, suggesting the possibility that this might represent a focus for future thrombosis. We conclude that noninvasive testing as used herein is an accurate method of assessing the carotid artery following endarterectomy. The accuracy of these techniques has been of such high degree that 16 carefully selected patients have subsequently undergone carotid endarterectomy without preoperative angiography. (J VASC SURG 1984;1:403-8.)     

Risk factors for surgical-site infections in head and neck cancer surgery.

OBJECTIVE: The aim of this study was to identify risk factors for surgical-site infections (SSIs) in patients with head and neck cancer submitted to major clean-contaminated surgery. STUDY DESIGN: This is a prospective study conducted in a tertiary cancer center hospital. SUBJECTS AND METHODS: This study includes 258 patients submitted to a major clean-contaminated head and neck oncologic surgery. RESULTS: The overall SSI rate was 38.8%. The univariate analysis showed the following significant risk factors: race, tobacco consumption, clinical stage, comorbidities, time duration of the surgical procedure, and flap reconstruction. The final model by logistic regression identified the following independent predictors for SSI: tobacco consumption (odds ratio [OR] = 2.96), presence of metastatic lymph nodes (OR = 2.05), flap reconstruction (OR = 2.20), and antimicrobial prophylaxis exceeding 48 hours (OR=1.89). CONCLUSION: The high-risk patients for SSI in head and neck oncologic surgery were those with cancer at advanced stages, those who were smokers, those presenting comorbidities, those who needed major reconstruction of the surgical wound, or those who were submitted to inadequate antibiotic prophylaxis.     

Risk factors for surgical site infection following spinal instrumentation surgery

Background

In spinal instrumentation surgeries, surgical site infection (SSI) is one of the complications to be avoided. However, spinal instrumentation surgeries have a higher rate of SSI than other clean orthopedic surgeries. The purpose of this study was to investigate the risk factors for SSI following spinal instrumentation surgeries and contribute to the prevention of SSIs by identifying high-risk patients.