Vascular complications of percutaneous femoral cardiac interventions. Incidence and operative repair

Of 7333 patients undergoing percutaneous left-heart catheterization procedures during a seven-year seven-month period, 73 patients (1%) underwent 75 operative repairs of catheterization-related vascular complications. The overall incidence of operative repair varied according to the type of percutaneous femoral artery procedure performed: 0.6% for diagnostic heart catheterization, 0.9% for percutaneous transluminal angioplasty, 5.2% for transfemoral balloon valvuloplasty, and 11.5% for intra-aortic balloon pump placement. This suggests that (1) femoral and iliac artery occlusions can and should be repaired promptly while the patient is under local anesthesia; (2) false aneurysms in this clinical setting can be approached directly through the aneurysm cavity; (3) the diagnosis of false aneurysm or arteriovenous fistula can usually be made on clinical grounds alone, without resorting to angiography; (4) venous or arterial patch angioplasty is the preferred technique for small or severely traumatized femoral arteries; and (5) the necessity for operative repair of these lesions will continue to increase in frequency as percutaneous cardiologic diagnostic and therapeutic interventions are used more widely.     

卵巢动脉栓塞术的研究进展及临床意义

近年来,子宫动脉栓塞术(UAE)已成为公认的替代外科手术治疗子宫肌瘤的方法.选择性卵巢动脉栓塞术(OAE)在技术上安全有效,UAE联合OAE治疗与单纯UAE治疗比较,在绝经的发病率、绝经样症状的严重程度方面无差异.但目前还需进一步明确OAE对卵巢储备功能的血清标志物及卵巢血管的影响.本文对卵巢动脉的解剖、血管造影及栓塞技术、OAE后卵巢功能的研究进展进行综述.     

Impact of diabetes mellitus on outcomes of superficial femoral artery endoluminal interventions

BACKGROUND: Although aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of diabetes mellitus (DM) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without DM. METHODS: A database of patients undergoing endovascular treatment of the SFA between 1986 and 2005 was maintained. Three groups were defined: nondiabetic patients, those with non-insulin-dependent DM (NIDDM), and those with insulin-dependent DM (IDDM). Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC) and Society for Vascular Surgery criteria. Time-dependent outcomes were assessed with Kaplan-Meier survival analyses. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SD where appropriate. RESULTS: Endovascular treatment (ie, balloon angioplasty +/- adjuvant stenting in 38%) was initiated in 525 limbs in 437 patients (68% male; average age, 66 +/- 14 years) for claudication failing conservative therapy or chronic critical limb ischemia (CLI). Of these, 50% were nondiabetic, 26% had NIDDM, and 24% had IDDM. Analyses were separated by those presenting with claudication (61%) and those presenting with CLI (39%). Among patients presenting with claudication, those with IDDM had significantly lower assisted primary patency (P < .01) and a higher incidence of restenosis (P = .04). Patencies at 3 years for nondiabetic, NIDDM, and IDDM were 62%, 72%, and 54% (primary), and 81%, 86%, and 65% (assisted primary), respectively. Patency and restenosis rates were associated with lesion calcification, TASC D lesion categorization, and acute periprocedural occlusion. Among patients presenting with CLI, patency and restenosis rates were equivalent across all groups; however, limb salvage was significantly worse for both groups of diabetic patients compared with nondiabetic (NIDDM, P = .01; IDDM, P = .02). Reduction in limb salvage rates was associated with presence of tissue loss at presentation, end-stage renal disease, and progression of distal disease on follow-up. CONCLUSIONS: Endoluminal therapy for SFA occlusive disease yields lower assisted patency rates and higher restenosis rates for those patients presenting with claudication who have more advanced diabetes (ie, IDDM). Among those patients presenting with CLI, particularly those with tissue loss, limb salvage rates are lowered for the diabetic groups (NIDDM and IDDM) despite equivalent patency and restenosis rates.     

下肢动脉支架与单纯球囊扩张成形治疗股浅动脉病变的对比性研究

目的观察并比较单纯经皮血管腔内成形(PTA)与自膨式镍钛记忆合金支架植入治疗下肢缺血的疗效。方法对2005年1月～2006年6月支架治疗61例患者的临床资料进行回顾性研究,包括22例(36.1%)PTA(PTA组)和39例(63.9%)球囊扩张后的支架植入(支架组)。49例(80.3%)患者为糖尿病下肢动脉硬化,12例(19.7%)为非糖尿病下肢动脉硬化。3例(4.9%)为严重间歇性跛行,20例(32.8%)有静息痛,25例(41.0%)伴有足部溃疡,13例(21.3%)有足部坏疽。结果 PTA组和支架组的总有效率分别为95.5%和94.9%,两组近期疗效无明显差异(P0.05);平均随访15.5个月,PTA组和支架组的总有效率分别为68.2%和89.7%,支架的疗效明显优于单纯PTA(P0.05)。PTA组和支架组的截肢率分别为13.6%和2.6%,两组在保肢方面无明显差异(P0.05)。结论对于治疗股浅动脉病变所导致的下肢缺血的疗效,在短期内单纯PTA与支架植入没有明显差异,而在术后1年的随访中股浅动脉支架的疗效明显优于PTA。两组救肢效果在术后1年左右也基本相同。     

Endarterectomy of the superficial femoral artery.

Semiclosed endarterectomy of the SFA belongs in the armamentarium of the vascular surgeon. New technology offers the possibility of performing this less invasive operation so that only a single incision is needed to obtain access to the artery and perform remote disobliteration. Strong indications show that the anticipated restenosis of long, segmental, closed endarterectomies can be reduced remarkably by expanded PTFE endolining.     

Percutaneous angioplasty and stenting of the superficial femoral artery

OBJECTIVES: The objectives of this study were to examine factors predictive of success or failure after percutaneous angioplasty (PTA) and stenting (S) of the superficial femoral artery (SFA) and to compare the results of PTA/S with a contemporary group of patients treated with femoropopliteal bypass. METHODS: A database of patients undergoing PTA and/or S of the SFA between 1986 and 2004 was maintained. Intention-to-treat analysis was performed. Patients underwent duplex scanning follow-up at 1, 3, and every 6 months after the intervention. Angiograms were reviewed in all cases to assess lesion characteristics and preprocedure and postprocedure runoff. Results were standardized to current TransAtlantic Inter-Society Consensus (TASC) and Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazard analyses were performed to assess factors associated with patient survival and treatment efficacy. RESULTS: Three hundred eighty total limbs underwent PTA/S in 329 patients (67% male, 33% female; average age, 65 years). Mean follow-up was 1.8 years from the date of initial intervention. Indications for intervention were claudication in 66%, rest pain in 16%, and tissue loss in 18%. Runoff at the tibial level was 2.1 +/- 0.8 patent vessels. Mean SVS ischemia grade was 3.1 (range, 1 to 5). TASC lesion grades were A (48%), B (18%), C (22%), and D (12%). Angioplasty alone was used in 63% of cases. Primary treatment failure (inability to cross lesion) was seen in 7% of patients. There was one periprocedural death. Primary patency rates were 86% at 3 months, 80% at 6 months, 75% at 12 months, 66% at 24 months, 60% at 36 months, 58% at 48 months, and 52% at 60 months. Assisted primary patency rates were slightly higher ( P = not significant). By Cox proportional hazards analysis, patency of PTA/S was associated with higher preoperative ankle/brachial index ( P = .016) and the performance of angioplasty only ( P = .011). Failed or occluded PTA/S was associated with TASC C ( P < .0001) and TASC D lesions ( P < .0001). Patient death was associated with the presence of congestive heart failure ( P = .003). Subgroup analysis revealed that primary patency rates are highly dependent on lesion type (A > B > C > D, P < .0001). PTA/S patency for TASC A and B lesions compared favorably to prosthetic and venous femoropopliteal bypass. Surgical bypass was superior to PTA/S for TASC C and D lesions. CONCLUSIONS: PTA and stenting of the SFA can be performed safely with excellent procedural success rates. Improved patency of these interventions was seen with increased ankle/brachial index and the performance of angioplasty only. Worse patency was seen with TASC C and TASC D lesions. Patency rates were strongly dependent on lesion type, and the results of angioplasty and stenting compared favorably with surgical bypass for TASC A and B lesions.     

Ruptured aneurysm of the superficial femoral artery.

Femoral arterial aneurysms are rare, but their existence must be considered in cases of acute ischaemia of the leg or the occurrence of a pulsating swelling in the groin. Surgical intervention is mandatory, and venous autografts should be preferred to synthetic grafts. With adequate therapy, the prognosis is favourable, but the coexistence of multiple aneurysms should always be borne in mind. A successfully treated case of ruptured femoral aneurysm, combined with abdominal aortic aneurysm, is reported.     

Salmonella-related mycotic pseudoaneurysm of the superficial femoral artery

IntroductionMycotic pseudoaneurysms of native arteries are rare. Treatment involves arterial excision with or without revascularization.Presentation of caseA 49-year-old diabetic man presented with a 4-month history of progressive left mid-thigh pain, associated with a pulsatile mass and fever. Clinically, he appeared to have a mycotic pseudoaneurysm, which was confirmed by computed tomography. The aneurysm was excluded from the circulation by an extra-anatomical bypass graft using autologous vein.ConclusionNative arterial mycotic pseudoaneurysms typically occur in immuno-compromised patients. They may be successfully treated using autologous vein bypass.DiscussionArterial infection is associated with immunosuppressive states and Staphylococcus aureus is the most commonly isolated organism in mycotic aneurysms. Also, Escherichia coli, Salmonella sp. and anaerobic species have been identified. Salmonella species are associated with mycotic aneurysms in the abdominal aorta and the use of autogenous vein grafts is the standard treatment for this condition. In lower extremities, autogenous conduits have been already used with good results of patency and freedom from re-infection. Endovascular treatment is a feasible approach in these situations, but there is not reports regarding long term results and this treatment is occasionally associated with prosthesis infection.     

Degenerative aneurysms of the superficial femoral artery.

PURPOSE: To review the pathogenesis, diagnosis, presentation, diagnosis, management and outcomes (morbidity and mortality) of superficial femoral artery aneurysms. METHODS: A comprehensive review of this entity was performed based on the available literature in all languages and a detailed discussion of our findings is also provided. RESULTS: Our review identified 61 cases of SFA aneurysms. They were most often seen in elderly men, predominately affected the right lower extremity, and were most often located in the middle-third of the artery. At the time of diagnosis, SFA aneurysms were frequently symptomatic because they reached a relative large diameter before the diagnosis was made. The most frequent presentation was localized pain in association with a pulsatile mass. In contrast to popliteal aneurysms, SFA aneurysms more frequently present with rupture than distal ischemia. Angiography was by far the most commonly utilized diagnostic tool. Treatment was primarily by means of an interposition graft, followed by exclusion and surgical bypass. Endovascular repair of SFA aneurysms has only been reported in three instances. SFA aneurysm repair was most often associated with favorable outcomes, with low reported rates of ischemia and limb loss.