Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers

BACKGROUND: Iliocaval venous obstruction (ICVO) can be a significant contributor to venous hypertension in patients with advanced disease. The incidence of ICVO in patients with CEAP clinical class 5 and 6 disease has not been reported. In this study, we reviewed a series of patients with healed or active venous leg ulcers to determine the incidence of ICVO and the risk factors related to its occurrence. METHODS: Patients with CEAP clinical class 5 and 6 venous insufficiency underwent evaluation with duplex ultrasound scan to identify the presence of venous reflux in the deep and superficial systems and either computed tomography (CT) or magnetic resonance (MR) venography to identify ICVO. The venograms were evaluated by two separate examiners to calculate the percentage of obstruction in the iliocaval outflow tract. Demographics and risk factors related to venous disease were collected and examined for their association with severe ICVO. RESULTS: A total of 78 CEAP clinical class 5 and 6 patients evaluated with either a CT or MR venogram were retrospectively reviewed. The average patient age was 59.3 years and 53.4% were men. The ulcer affected the left lower extremity in 46% of cases and 50% of patients reported a medical history of deep vein thrombosis (DVT). Overall, 37% of imaging studies demonstrated ICVO of at least 50% and 23% had obstruction of >80%. Risk factors that were found to be independently associated with a significantly higher incidence of >80% ICVO included female gender (P = .023), a medical history of DVT (P = .035), and reflux in the deep venous system (P = .035). No limb with superficial venous reflux (SVR) alone was found to have ICVO >80%. CONCLUSIONS: ICVO is a frequent and underappreciated contributor to venous hypertension in patients with venous leg ulcers. Women and patients with a history of DVT or duplex scan-diagnosed deep venous reflux (DVR) have a higher incidence of outflow obstruction and should be routinely studied with CT or MR venography to allow correction in this high-risk group of patients

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency

Objective: Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment. Methods: Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined. Results: Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n=34) were factors that were independently associated with delayed healing (P < .01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to$2711. Conclusion: The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency. (J Vasc Surg 1999;30:491-8.

Extrathoracic reconstruction of arterial occlusive disease involving the supraaortic trunks

Purpose: The purpose of this study was to review the various extrathoracic reconstruction options in patients with occlusive disease of the supraaortic trunks and to define the efficacy of these procedures in maintaining graft patency and relieving symptomsMethods: Forty-four consecutive patients underwent 47 extrathoracic bypass procedures of the supraaortic trunks for correction of symptomatic subclavian (SCA), common carotid (CCA) or innominate (INA) artery occlusive disease between July 1975 and May 1994. SCA stenosis (n = 27) was associated with upper extremity claudication (55%), vertebrobasilar insufficiency (15%), or both (30%). CCA stenosis (n = 14) was accompanied by hemispheric symptoms in 86% and global ischemia in 14%, whereas INA stenosis (n = 3) was associated with transient ischemic attacks (67%) and right arm ischemia (33%).Results: SCA revascularization included carotid-subclavian or carotid-axillary bypass (n = 19), axilloaxillary bypass (n = 8), and subclavian-carotid transposition (n = 3). CCA reconstructions included subclavian-carotid (SC) bypass (n = 13) and carotid-carotid bypass (n = 1 ). INA procedures included three axilloaxillary bypasses. Six patients had an associated carotid endarterectomy, and three underwent concomitant vertebral artery transpositions. Intraluminal shunts were not routinely used. Vein was used as a conduit in five procedures, and a prosthetic graft (23 Dacron, 16 polytetrafluoroethylene) was used in the remainder. The average postoperative intensive care unit and hospital stay were 1 and 5 days, respectively. Follow-up was available in 43 of 44 patients (mean = 26.2 months). The perioperative morality rate was 2.2% (one axilloaxillary). There were five graft occlusions in procedures involving the axillary artery (3 of 11 axilloaxillary, 2 of 7 carotid-axillary) as compared with one of 29 thromboses when the operation was confined to the supraclavicular fossa (p < 0.05). Relief of symptoms was achieved in all patients with patent grafts. There were no perioperative strokes in the series. Other complications included one brachial plexus neuropraxia (axilloaxillary) and four patients with phrenic nerve neuropraxia.Conclusion: Extrathoracic revascularization of the supraaortic trunks is well tolerated and durable when operations are confined to the supraclavicular fossa and do not involve the axillary artery. (J VASC SURG 1995;22:217-22.

Coverage of the left subclavian artery during thoracic endovascular aortic repair

BackgroundThoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions.MethodsBetween October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.ResultsMean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures.ConclusionIntentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions

Carotid artery trauma: A review of contemporary trauma center experiences

AbstractPurpose: Many issues surrounding the management and outcome of carotid artery injuries remain controversial. The purpose of this study was to review a large contemporary experience with such injuries in the setting of designated trauma centers.Methods: A statewide computerized trauma registry was used to identify all patients with injuries to the common or internal carotid arteries from October 1987 to June 1993. The records of 82 such patients were retrieved and analyzed.Results: Overall mortality and stroke rates were 17% and 28%, respectively. Patients presenting with coma or shock had a particularly bad prognosis (50% and 41% mortality, respectively). Internal carotid injuries resulted in mortality and stroke rates of 21% and 41%, respectively, compared with 11% each for common carotid injuries. Patients with blunt injuries had a much higher stroke rate (56% vs 15%) but had lower mortality (7% vs 22%) than did patients with penetrating injuries. Airway compromise and associated injuries did not affect prognosis. Operative repair and percutaneous balloon occlusion had the best survival and functional outcomes.Conclusions: Operative repair offers the best chances for recovery in all categories of patients regardless of injury mechanism. Ligation is useful only as a last-resort lifesaving effort. Shock and neurologic impairment are poor prognostic factors but should not negate repair. (J VASC SURG 1995;21:46-56.

Management and outcome of chronic atherosclerotic infrarenal aortic occlusion

Abstract Purpose: To evaluate the management and outcome of chronic atherosclerotic infrarenal aortic occlusion (IRAO), a review of 48 patients who were treated for angiographically documented IRAO between January 1980 and December 1994 was undertaken. Mean follow-up was 45 months. Mean age was 57 years (range, 33 to 88 years). Forty-seven patients were heavy smokers. Symptoms included claudication in 81%, rest pain in 25%, and tissue loss in 15%. Impotence was documented in 73% of men. Associated arterial disease included inferior mesenteric artery occlusion in 31 patients, renal artery stenosis or occlusion in 12, superior mesenteric artery stenosis in two, and celiac artery stenosis in one.Methods: Forty inflow procedures were performed, including 17 thoracobifemoral bypass (TBF) procedures, 15 aortobifemoral/iliac bypass (ABFI) procedures, and eight axillo-bifemoral bypass (AXBF) procedures. Eight patients were managed without surgery. The thoracic aorta was chosen as the inflow source in 17 patients because of previous abdominal aortic surgery in eight, poor status of the abdominal aorta in eight, and horseshoe kidney in one. Results: The overall operative mortality rate was 5%, and the perioperative morbidity rate was 18%. There was no statistical difference in perioperative mortality and morbidity rates among the operative groups. The five-year survival rate (life-table) for all IRAO patients was 67%. TBF and ABFI revascularization procedures yielded 5-year patency rates of 71% and 79%, respectively ( p 2.0 mg/dl were documented in three operative patients and in one nonoperative patient, and none required dialysis.Conclusions: In patients who have IRAO, aorta-based inflow procedures are superior to AXBF both in hemodynamic outcome and in patency rates. Treatment of IRAO with TBF or ABFI yields similar long-term results; the descending thoracic aorta represents an excellent inflow alternative to the abdominal aorta. Clinically significant renal impairment is rarely associated with IRAO. Nonoperative management of IRAO is associated with an increased mortality rate and a high rate of limb loss. (J Vasc Surg 1996;24:394-405.

Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

Abstract Purpose We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency. Methods This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery. Results Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 ± 2.9 preoperatively to 2.2 ± 1.3 after surgery (P < .001); EF improved from 56.3 ± 18 to 62 ± 21 (P = .02); and RVF improved from 40.1 ± 19 to 28.3 ± 18 (P = .009). Mean preoperative symptom score (5.3 ± 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 ± 1.2; P < .001). Conclusion Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery

Prediction of wrist arteriovenous fistula maturation with preoperative vein mapping with ultrasonography

Objective: The purpose of this study was to determine whether the preoperative minimal cephalic vein size in the forearm was predictive of successful wrist fistula maturation to a functional hemodialysis access. Methods: Forty-four consecutive patients underwent evaluation before surgery with ultrasound scan imaging to map the entire cephalic vein in preparation for the construction of an arteriovenous fistula at the wrist. Measurements of the vein diameter were obtained from the ultrasound scan images at eight representative sites. Patients were clinically followed to determine maturation of the fistula to provide a functional hemodialysis access. The smallest diameter of the cephalic vein then was used as a preoperative predictor of fistula maturation. Results: Successful maturation of the arteriovenous fistula was achieved in 22 of the procedures (50%). Cephalic veins with a minimal diameter of 2.0 mm or less were used for anastamosis in 19 patients (43%), and three of these procedures (16%) led to a functional access site. The remaining 25 patients (57%) had minimal cephalic vein diameters greater than 2.0 mm, producing a successful maturation in 19 of the fistula creations (76%). A significantly higher rate of successful fistula maturation in those patients with a preoperative minimal cephalic vein size greater than 2.0 mm was realized (P = .0002, χ2 test, with Yates correction for continuity). Conclusion: In patients with a minimal cephalic vein size of 2.0 mm or less, a procedure other than wrist fistula should be considered for optimization of dialysis access. (J Vasc Surg 2002;36:460-3.

Distal thoracic aorta as inflow for the treatment of chronic mesenteric ischemia

Purpose: Mesenteric revascularization for chronic mesenteric ischemia (CMI) traditionally involves antegrade or retrograde bypass graft originating from the supraceliac or infrarenal aorta. The distal thoracic aorta (DTA) may provide a better inflow source than the abdominal aorta. The purpose of this study was to evaluate the results with the DTA used as inflow for the surgical treatment of CMI. Methods: All patients undergoing mesenteric revascularization for CMI with grafts originating from the DTA were identified from 1990 to 1999. A ninth interspace thoracoretroperitoneal incision was used for exposure, and distal aortic flow was maintained by use of a partial occlusion clamp. Results: Eighteen consecutive patients with CMI underwent mesenteric bypass grafting with the DTA used as inflow. All patients were admitted with chronic abdominal pain or weight loss, with two (12%) requiring urgent revascularization because of acute exacerbation of chronic symptoms. Fourteen (78%) patients had both celiac and superior mesenteric artery bypass grafts placed, and three (17%) patients had superior mesenteric artery grafts alone. There was one (6%) perioperative death and three (17%) major complications. There was no kidney failure, mesenteric infarction, or spinal cord ischemia. The life-table survival rate was 89%, 89%, and 76% at 1, 3, and 5 years, respectively. All 18 patients remained symptom free and required no additional procedures to assist patency. There was no evidence of graft stenosis or occlusion (100% patency) for those grafts evaluated objectively during the mean follow-up of 34.8 months (range, 1-97 months). Conclusions: Antegrade mesenteric revascularization with the DTA used as inflow is associated with low morbidity and mortality rates. Furthermore, it provides excellent midterm patency and survival results and should be considered as a primary approach for reconstruction of patients with CMI. (J Vasc Surg 2001;33:281-8.

Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction

Objective: Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. Methods: Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. Results: Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. Conclusion: These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve. ( J Vasc Surg 2005;41:191-8.