Extensive aorto-ilio-femoral endarterectomy with LeVeen plaque cracker

The authors present a series of 98 patients, who underwent an aorto-ilio-femoral endarterectomy according to the technique of LeVeen. The operative mortality was 1% with an adjusted early patency rate of 99%. For a total of 52 documented cases, erectile function was lost in 25%. Ejaculatory disorders were seen in 35 patients. With a mean follow-up period of 22 months (range 1 to 60 months) there were no occlusions in the aortoiliac group. Patency in the aortofemoral group decreased to 92.5% after 4 years. It is concluded that the results support continued use of the reported technique. A longer period of follow-up however is recommended to define its exact role in reconstructive surgery for aortoiliac occlusive disease.     

Extensive endarterectomy of the aorta, common and external iliac arteries, and common femoral arteries by a modified Le Veen method

It has been 8 years since Le Veen et al. described a new method of disobliteration of the distal aorta and iliac arteries. Since then no further reports have appeared in the literature. During the past 2 1/2 years we have treated 23 patients with severe ischemia of the lower limbs, caused in most cases by severe and multilevel arterial occlusions (types II and III), which included the infrarenal aorta, common and external iliac arteries, and common femoral arteries, with the method of Le Veen et al. with some modifications in the technique. A satisfactory revascularization was obtained in all patients. Similarly, there were no operative deaths or morbidity and no early or late arterial occlusions. We conclude that this method of arterial disobliteration has certain advantages over the much more widely used bypass grafting, deserves an extensive trial, and could in the future become a well-accepted procedure to treat extensive occlusions of the distal aorta, common and external iliac arteries, and common femoral arteries.     

Calcified plaque is common in the carotid and femoral arteries of dialysis patients without clinical vascular disease

Background. Cardiac and vascular mortality are common in end-stage renal disease (ERSD) and are often attributed to accelerated atherosclerosis. Subjects and methods. We studied 24 non-diabetic ESRD patients without cardiac or vascular disease (M = 12, F = 12) and 24 age-, sex- and race-matched healthy controls. All underwent B-mode ultrasound for carotid and femoral intima-media thickness (IMT) and plaque (% stenosis) together with blood pressure (BP), and echocardiograms to determine left ventricular mass. Results. Both BP and mean IMT were similar in patients and controls. However, discrete plaque was present in 71% (17/24) of patients compared with 21% (5/24) of controls (P = 0.001), and % stenosis was greater in patients (carotid 12.2 ± 11% vs 2.3 ± 5.9%, P <0.0004; femoral 16.4 ± 19.1% vs 3.1 ± 6.4%, P <0.003). Plaque was soft/atheromatous in 3 of the 5 controls, but not in any of the 17 patients (P = 0.007), all of whom had calcified lesions. BP and cholesterol were not correlated with IMT or plaque in patients, but in control subjects carotid IMT was correlated with systolic BP (r = 0.66, P <0.0005) and diastolic BP (r = 0.45, P <0.03). In patients, the only independent variables related to vascular morphology were serum albumin which was inversely related to IMT (P <0.03) and to plaque (carotid P <0.05, femoral P <0.02) and age, which was related to femoral plaque only (P <0.04). Left ventricular end-diastolic internal dimension not LVMI, correlated positively with carotid IMT (P <0.04). Conclusion. Our results show that calcified plaque is common in ESRD patients and hypoalbuminaemia may be an associated factor. Keywords: B-mode ultrasound; carotid and femoral artery; end-stage renal disease; calcification      

Cystic adventitial disease of the common femoral and popliteal arteries

Cystic adventitial arterial disease (CAAD) is usually situated in the popliteal artery and is a well recognized cause of intermittent claudication in otherwise healthy, young, non-smokers. Three cases of CAAD have recently been encountered, involving the popliteal artery in two patients and the common femoral in one. Two of these patients were hypertensive smokers in their sixth decades and only one was an otherwise healthy non-smoker, but all three had a characteristically rapid onset of symptoms. All had angiographic appearances suggestive of CAAD, confirmed by ultrasound and CAT scanning in one patient. Two were treated by resection of the affected artery and a replacement graft, both with excellent results. One popliteal lesion was bypassed with a vein graft which occluded after 3 months. CAAD may occur more commonly than generally realized. It can present in patients whose condition suggests an atheromatous cause for their symptoms. Since good results can be expected from appropriate surgical treatment in most cases, CAAD should be considered in the diagnosis of all patients with claudication, particularly when the onset has been rapid.     

New method of simultaneous disobliteration of the visceral arteries and abdominal aorta

Simultaneous correction of abnormal blood flow is necessary in the presence of combined lesions of various branches of the abdominal aorta. The problem can be solved comparatively easily by using transaortic endoarteriectomy, a technique proposed here, which consists essentially of longitudinal incision of the aortic lumen and simultaneous endoarteriectomy under the visual control of the abdominal aorta, the visceral branches and the renal arteries. Personal experience is based on 21 operations for cases of atherosclerosis and aspecific sclerotic aorta-arteritis. Simultaneous transaortic endarteriectomy is indicated in the presence of lesions localized at the proximal segment of more than two branches of the abdominal aorta. In 4 of the cases observed it was associated with resection and prosthesis of the lesioned segment of the artery and in 9 cases with resection of the abdominal aorta and aorto-femoral prosthesis. Clinical succe-s was achieved in 10 cases (90.5%).     

Simultaneous operations at coronary arteries and aorto-iliac zone

Cardiac complications after operations on aorto-iliac segment take the leading place, and they are the main cause of postoperative lethality achieving 40%. Experience of 10 simultaneous operations on coronary and aorto-iliac zone with original method of aorto-femoral bypass from mini-approach is analyzed. The types and stages of simultaneous reconstructions are described. The clinical case of simultaneous operations on brachiocephal, coronary and lower limb arteries is presented with characteristics of surgical stages and the main intra- and postoperative parameters. Mini-invasive methods permit to expand the indications for simultaneous operations on different vascular segments at the patients with multifocal atherosclerosis.     

Isolated proximal revascularization for double aorto-iliac and femoral lesions]

From 1980 to 1990, 101 limbs were revascularized at the upper level only in 67 patients, while they presented with associated aortoiliac and femoral obstructive lesions. The symptoms disappeared after aortofemoral revascularization in 94% of the limbs operated on for claudication and 80% of those operated on for critic ischemia. Surgery of the deep femoral artery was associated in 51% of all cases. The average time lapse is 58 months. No complementary revascularization was needed in the cases of claudication. Out of the patients operated on for critic ischemia, upper revascularization was insufficient in 8 cases. Two of the operated patients were cured after secondary downstream revascularization (4%). Three operated patients still presented with intermittent claudication (6%), and 3 were amputed due to acute iliac obstruction seen at an advanced stage. As no reliable predictive test is available, we find it justified to carry out only upper revascularisation in most cases and to decide on the need for secondary downstream extension according to the clinical outcome. However, simultaneous revascularization at both levels is required in case of extensive involvement of the deep femoral artery, such as observed in only 5 of the patients operated during the same period.     

Rare origin of the inferior epigastric and medial circumflex femoral arteries arising from a common trunk

A case of unilateral anomalous arterial supply of the lower limb and the anterior abdominal wall is presented. In this case, inferior epigastric artery arose from a common trunk with the medial circumflex femoral artery. The common trunk arose from the femoral artery. The inferior epigastric artery reached the anterior abdominal wall by passing deep to the inguinal ligament. The medial circumflex artery ran between the femoral artery and vein within the femoral triangle. A possible ontogenetic explanation is provided for this situation. Awareness of the variations in anatomy of the inferior epigastric and femoral arteries is important for angiographers and the surgeon who operates in this region. Received: 28 October 1999 / Accepted: 10 July 2000     

Long term follow-up of descending thoracic aorto-iliac/femoral bypass

A prospective study of 26 patients undergoing descending thoracic aorto-iliac/femoral (DTAI/F) bypass was conducted over a 13-year period with an average follow up of 53 months. Reasons for selecting the procedure were occluded aortic bifurcation grafts (9 patients), hostile abdomen (6), infected aortic graft (1), microaorta (10, and surgeons preference in 8 patients who had juxtarenal aortic occlusion. The operative mortality was 3.8% (1 patient). A late mortality of 36% was due to myocardial infarction (1), lung carcinoma (2), renal failure (4), stroke (1) and pulmonary insufficiency (1). Graft failure occurred in 4 patients at 23, 26, 54 and 109 months respectively. Primary cumulative patency was 86% statistically valid at 42 months. DTAI/F bypass is recommended in selected patients when conventional approaches to the aorta are considered unduly hazardous.     

Endarterectomy of the femoral and popliteal arteries

The experience of 127 operations for endarterectomy of occlusions of the femoral and popliteal arteries in 122 patients is analyzed. The remote results were observed for 10 years. The cumulative analysis within 10 years after operations have shown 27% of endarectomized arteries to remain passable. The best results were obtained when using the gaseous method modified by the authors, for correction of short occlusions in combination with good outflow pathways. With this form of pathology 68% of arteries are found to be passable within 10 postoperative years.     

A comparison of acute phase proteins and traditional risk factors as markers of combined plaque and intima-media thickness and plaque density in carotid and femoral arteries.

OBJECTIVES: To test the hypothesis that some acute phase proteins may be better independent predictors of objective measures of arterial wall impairment than traditional risk factors. DESIGN: Cross-sectional study. MATERIALS AND METHODS: C-reactive protein (CRP), fibrinogen, C3 complement and traditional risk factors were measured in 288 men aged 55-64 years, randomly chosen from the local registry lists. By ultrasound assessment of the bifurcations of carotid and femoral arteries, maximum combined plaque/intima-media thickness (CPIMTmax) and mean plaque density (MPD, in a grey scale from 0 to 255) were also measured. RESULTS: In multivariate analysis only traditional risk factors remained associated with the overall CPIMTmax: smoking (r = 0.35, p < 0.0001), cholesterol (r = 0.23, p = 0.0001), age (r = 0.22, p = 0.0002), glucose (r = 0.18, p = 0.002) and systolic blood pressure (r = 0.13, p = 0.02). However, with regard to carotid disease only, fibrinogen was the strongest covariate of CPIMT (r = 0.18, p = 0.002). The overall MPD was independently associated with CRP (r = 0.25, p = 0.0008), physical activity (r = 0.19, p = 0.009), triglycerides (r = -0.18, p = 0.02) and body mass index (r = 0.15, p = 0.04). CRP was mainly associated with femoral MPD, while triglycerides were the major (inverse) covariate of carotid MPD. CONCLUSIONS: Traditional risk factors are the main determinants of CPIMTmax, although fibrinogen seems to play a role in carotids. CRP was associated with high density femoral plaques. Finally, no acute phase protein was independently associated with low density, potentially vulnerable, plaques.     

Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique

OBJECTIVE: Percutaneous access during endovascular aortic repair has been shown to be feasible and safe using a suture-mediated closure device ("Preclose" technique) for closure of up to 24F introducer sheaths. The purpose of this study is to examine the late outcomes of those femoral arteries repaired in this manner. METHODS: The Preclose technique has been previously described. Briefly, the technique involves two Perclose Proglide devices deployed in the femoral artery prior to insertion of the large diameter introducer sheath and then closure of the arteriotomy by tying down knots of the Proglide following removal of the sheath. The medical records of all patients who underwent endovascular aortic repairs using the Preclose technique between December 2004 and August 2007 were reviewed. Follow-up protocol consisted of computed tomography (CT) angiograms performed at 1, 6, and 12 months, and annually thereafter. All Preclose patients who had at least a 6-month postoperative scan were included in the study. For each patient, the most recent postoperative scan was compared with the preoperative scan for evidence of any new anatomic abnormalities of the femoral artery such as dissection, stenosis, or pseudoaneurysm. Three-dimensional post processing with multiplanar reconstructions was also performed as necessary to confirm axial scan findings. RESULTS: A total of 292 patients underwent percutaneous endovascular aortic repairs (TEVAR-125, EVAR-167). Four hundred thirty-two femoral arteries were closed with 870 devices. Four hundred eighteen vessels were approximated with two devices, while 30 arteries required three devices for hemostasis and an additional four vessels only required a single device. Two hundred seventy-eight (64.3%) vessels were accessed with sheaths 18 to 24F. Four hundred eight femoral arteries (94.4%) were closed successfully with the Preclose technique. There were 100 patients (TEVAR-35, EVAR-65) who had adequate postoperative CT scan at 6-months or later. The mean follow up was 11.6 +/- 5.0 months. Of the 156 femoral arteries in these 100 patients repaired using the Preclose technique, there were 3 late complications in 3 patients, 1 asymptomatic femoral artery dissection, and 2 femoral artery pseudoaneurysms requiring surgical repair, resulting in a late complication rate of 1.92% (3/156). CONCLUSION: Percutaneous closure of femoral arteries after large diameter introducer sheaths using the Preclose technique has a low incidence of early and late complications related to the closure site.