Background: While much has been written about multiple methods of neuromonitoring during carotid endarterectomy (CEA), there has been relatively little discussion of the use of triple monitoring via somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) in conjunction with electroencephalography (EEG). Our objective was to evaluate the rate of detection and prevention of neurologic events by multinerve SEP, MEP, and EEG in patients undergoing CEA while under general anesthesia.Methods: A prospective study of 181 consecutive patients undergoing CEA between June 2005 and September 2010 was reviewed. Intraoperative changes, including a 50% reduction in the amplitude of SEP waveforms, loss of MEP, and/or a 50% change in EEG frequency were noted as indications for shunting. This was correlated with the actual use of intraoperative shunting and postoperative neurologic sequelae at both 24 hours and 30 days. Median and tibial nerve SEPs and MEPs were also correlated.Results: Eleven patients (6%) experienced intraoperative monitoring changes (SEP: 11/11; MEP: 6/11). Five of 11 patients with MEP/SEP changes underwent shunting, while the other 6 had normalization with the elevation of their blood pressure. Of the 11 patients that had neurophysiologic changes, 54% (6/11) were patients with symptomatic disease. No patients had significant EEG changes. The total shunt rate was 2.7% (5/181). No postoperative neurologic sequelae were noted.Conclusion: The ratio of shunting at 2.7% is equal to the lowest rates reported in the awake patient literature. Interestingly, the predicted synergy of multimodality monitoring cannot be directly attributed to an increased specificity resulting from the addition of SEP and MEP to EEG, because no patients had EEG changes. In addition, in today's cost-conscious world of health care, our results do not justify implementing this particular technique of neuromonitoring across the board-but it is apparent that the combination of these 3 modalities is both safe and effective with potential applications in symptomatic patients.

SUMMARY Peripheral artery disease (PAD) is a common, chronic atherosclerotic disease affecting millions of individuals that causes a major impact on morbidity and cardiovascular mortality. Although the gender- and age-specific prevalence of PAD has been well-defined from published population-based studies, the clinical relevance of these data has not been fully recognized by the public and health professionals. These health facts are now revealing that women suffer the consequences of PAD at rates at least as high as those observed in men. Additionally, PAD is more common in African–Americans over the age of 50 years than in non-Hispanic caucasians, suggesting that African–American women are at particularly high risk for developing PAD. Cardiovascular disease is the leading cause of death in women, making it imperative that the contribution of PAD be included in all future women's 'heart health efforts'.

Background: Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat. Patients with an ankle-ebrachial index (ABI) of 0.5-0.8 have been shown to heal poorly. Because adequate compression therapy is contraindicated in patients with an ABI of <0.7, we decided to undertake an aggressive approach of percutaneous revascularization for these patients.Methods: A total of 27 patients with clinical and duplex scan evidence of chronic venous insufficiency, active leg ulcers, and impaired arterial perfusion (ABI: <0.7) were treated using a protocol that required performing percutaneous revascularization before ambulatory compression therapy. The patients were followed at 2-week intervals (average) before and after revascularization. Wound measurements and time to complete closure were also recorded.Results: The results of the patients were compared with their own previous wound healing trajectories. Additionally, their healing rate was compared with previously published rates of impaired arterial perfusion venous wound closure; 25% closure at 10 weeks, 50% at 19 weeks. At enrollment, the average ABI and wound sizes were 0.56 and 12 cm(2), respectively. On average, the wounds had remained open for 17 weeks. After the intervention, the average ABI was 0.97, average time taken to complete closure was 10 weeks, closure rate at 10 weeks was 75%, and absolute closure rate was 100%.Conclusion: Although previous studies have shown that closure of mixed arterial venous ulcers occur without arterial intervention, attaining a near normal ABI allows for timelier wound closure. Therefore, we advocate an aggressive approach of percutaneous revascularization in this population.

les ulcères veineux actifs chez les patients avec insuffisance artérielle et veineuse associées sont notoirement difficile à traiter. Des patients présentant un index bras-cheville (IBC) de 0,5-0,8 ont connus pour mal guérir. Comme le traitement par compression est contre-indiqué chez les patients avec un IBC < 0,7, nous avons décidé d’adopter une approche agressive de revascularisation percutanée pour ces patients. Un total de 27 patients présentant selon des critères cliniques et écho-doppler une insuffisance veineuse chronique, des ulcères de jambe actifs, et une perfusion artérielle altérée (IBC: < 0,7) ont été traités en employant un protocole qui a exigé une revascularisation percutanée avant traitement ambulatoire par compression. Les patients ont été suivis à intervalles de deux semaines (moyenne) avant et après la revascularisation. Des mesures de la plaie et le temps de cicatrisation ont été également enregistrés. Les résultats des patients ont été comparés à l’évolution antérieure de leur plaie. De plus, leur taux de cicatrisation a été comparé aux taux précédemment publiés de cicatrisation d’ulcères veineux avec perfusion artérielle altérée; taux de cicatrisation de 25% à 10 semaines, 50% à 19 semaines. A l’inclusion, les IBC et les tailles des lésions moyens étaient de 0,56 et de 12 cm2, respectivement. En moyenne, les lésions étaient restées ouvertes pendant 17 semaines. Après l’intervention, l’IBC moyen était de 0,97, le temps moyen de cicatrisation complète était de 10 semaines, le taux de cicatrisation à 10 semaines était de 75%, et le taux absolu de cicatrisation était 100%. Bien que les études précédentes aient prouvé que la fermeture des ulcères veineux avec composante artérielle se produisent sans intervention artérielle, l’obtention d’un IBC presque normal permet de raccourcir le délai de cicatrisation. Par conséquent, nous préconisons une approche agressive de revascularisation percutanée dans cette population.

Although much is written about multiple methods of neuromonitoring during carotid endarterectomy (CEA), there is relatively little discussion of the use of somatosensory-evoked potentials (SEPs) especially multinerve SEPs in conjunction with electroencephalography (EEG). Our objective was to evaluate the rate of detection and prevention of neurologic events by multinerve SEP and EEG in patients undergoing CEA while under general anesthesia. A prospective study of 181 consecutive patients undergoing CEA between June 2005 and September 2010 was reviewed. Intraoperative changes, including 50% reduction in amplitude of SEP waveforms or a decrease in EEG amplitude, or both, were noted as indications for shunting. This was correlated with the actual use of intraoperative shunting and postoperative neurologic sequelae at 24 hours and 30 days. Median and tibial nerve SEPs and motor-evoked potentials (MEPs) were also correlated. Eleven patients (6%) experienced intraoperative monitoring changes; SEP, 11 of 11, MEP, 6 of 11; and 5 patients exhibiting MEP/SEP changes underwent shunting, while the other 6 had normalization with the elevation of their blood pressure. The total shunt rate was 2.7% (5 of 181). No postoperative neurologic sequelae were noted. The ratio of shunting at 2.7% is equal to the best rates reported in the literature of patients who are awake. This shunt ratio is lower than the centers performing EEG or median SEP monitoring. Comparing these data with the data in the current literature, it appears that the combination of three modalities performs better than a single modality, possibly because of better assessment middle, anterior, and perforating cerebral arteries.

Vascular graft infections in the femoral region that require synchronous revascularization are generally reconstructed with prosthetic grafts via extra-anatomic routes. If in situ revascularization is required, then autologous tissue provides optimal results. A particular challenge in this circumstance is achieving soft tissue coverage of the reconstruction where wide and radical débridement has removed the tissues ordinarily used for this purpose. If muscle flaps are not available or possible, the use of omentum is advocated. The omentum can be easily reached from behind the inguinal ligament and transposed on its bipedicled vascular base for coverage of vital structures in the femoral triangle, thereby obliterating dead space and providing a surface for both temporary and permanent skin coverage. The procedure is quite simple, can be performed rapidly, and should be considered for use in the dire situation that requires soft tissue coverage of exposed vessels in extraperitoneal locations. (J VASC SURG 1985;2:603-6.)

Adventitial cystic disease of the popliteal artery is an important cause of peripheral vascular insufficiency in the young and middle-aged man. The pathologic feature is a mucinous cyst located within the adventitia of the artery that expands and secondarily compromises the vessel lumen. Although physiologically quite different, this process is easily mistaken for arteriosclerosis. The clinical history of sudden claudication in a young nonsmoking man, combined with characteristic angiographic features, are important clues to the correct underlying pathology. Treatment generally consists of cyst evacuation or local bypass. This article was prompted by the failure of percutaneous transluminal angioplasty to achieve durable success in controlling this unique type of arterial disease. Subsequent surgical intervention proved satisfactory, lending support to this modality as the treatment of choice.

Intra-arterial thrombolysis with streptokinase was studied in 38 patients. The indications were peripheral thromboembolism in nine patients (group 1), postreconstruction graft thrombosis in 26 patients (group 2) and renal artery thrombosis in three patients (group 3). The intra-arterial route was used for the first and third groups and in 16 of the second group. The intravenous route was used in the remaining ten patients. Lysis was achieved in all of the group 1 and 3 patients. The latter were also treated with percutaneous transluminal angioplasty after dissolution of thrombus of the renal artery. In group 2 patients, lysis was achieved in eight of 16 patients in whom lytic therapy was instituted within seven days of graft closure. There was no lysis in all ten patients in whom elapsed time was more than seven days. Postlytic angiographic visualization of etiologic mechanisms for thrombosis enabled subsequent successful correction in three of five patients in group 2. Attempts to correct graft failure by surgical treatment when lysis had failed were often unsuccessful (12 of 17). Lytic therapy is most effective for acute embolic occlusion and for thrombosis of less than seven days duration. Although there is no difference in drug efficacy by route of administration, a lesser number of complications (such as, fever and hematoma) occurred with intra-arterial infusion. The effectiveness of lysis is also directly related to the collateral circulation and runoff beyond the occlusion. Lysis is not indicated for severe acute ischemia if surgical treatment is an alternative or if it may cause distal embolism as with complete axillofemoral graft thrombosis. Lytic therapy is least effective for graft thrombosis with pre-existent poor runoff.

Intraarterial thrombolysis by remote intravenous or direct intraarterial infusion of streptokinase is possible. The latter may be more effective with a lesser potential for systemic hemorrhagic complications because of the smaller dose administered directly in the area. Fifty patients with prosthetic graft, embolic, and renal artery occlusions were evaluated. Embolic occlusion responded dramatically, particularly since lytic therapy was initiated at an early stage. Patients with severe ischemia or those with simple localized occlusion were best treated by surgical means. Successful thrombolysis was also obtained with renal artery occlusions combined with percutaneous transluminal angioplasty. The management of patients with prosthetic graft occlusion by lytic therapy is complex. Optimal results can be obtained in patients presenting with occluded grafts after the immediate postoperative period and in those in whom previous satisfactory runoff has been demonstrated. Failure of lysis in this group is associated with a high incidence of limb loss due to unreconstructable obliterative disease. Successful lysis of occluded prosthetic grafts will often require corrective angioplasty or surgical revision.

Sixty-one distal arteriovenous fistulas (dAVFs) were constructed as adjuncts to tibial and peroneal vascular reconstructive procedures in 58 patients threatened with imminent limb loss. Specific indications for dAVF construction were absent or deficient pedal arches, usually associated with small, calcareous crural vessels. Conventional bypasses had been previously performed in 35 patients. Cumulative graft patency rates were 56%, 39%, and 18% at 6, 12, and 24 months, respectively. For the same intervals, the figures were 56%, 52%, and 52% (P less than 0.001 at 24 months) for nonAVF reconstructions (n = 49). The corresponding cumulative limb salvage rates were 62%, 52%, and 40% for the dAVF group and 78%, 72%, and 72% for the nonAVF group (P less than 0.05 at 24 months). The perioperative mortality rate was 7% (four of 61). Twenty-four amputations were required, of which 16 were below the knee and six despite patent grafts. There was no significant morbidity attributable directly to the dAVF. Cardiac output showed no deviations from normal values. Primary causes of early failure were infection (n = 4), absence of satisfactory veins (n = 6), and inappropriate case selection (n = 7). Intimal hyperplasia led to dAVF closure and graft failure in 13 patients. This study shows that dAVFs can maintain graft patency by diversion of the overload on a high-resistance vascular bed and, secondarily, by augmentation of inflow. Immediate survival of the limb still depends on the arterial runoff, as retrograde venous flow caused by venous valvular incompetence is a delayed development. Adjunctive dAVF is justified in selected cases where conventional bypass failure has occurred or is predictable by increased pedal vascular resistance.