OBJECTIVESto test whether the occurrence of microembolism differed between eversion and standard carotid endarterectomy (CEA).DESIGNprospective, non-randomised transcranial Doppler (TCD) monitoring study of 61 patients.MATERIALS AND METHODSeversion CEA was performed in 27 and standard CEA in 34 patients. Surgery was performed under general anaesthesia. Three (5%) patients had a shunt inserted based on continuous EEG monitoring. Continuous middle cerebral artery TCD monitoring (EME, TC-4040) was performed intraoperatively and for 45 min postoperatively on day 1, day 2-3, day 4-5 and after 3 months. Unidirectional signals lasting >25 ms, having intensities of >9 dB were considered to represent embolic events.RESULTSintraoperative embolic events were detected in 50 (93%) of 54 patients in whom successful intraoperative TCD monitoring was achieved. Events occurred most frequently immediately following clamp release (85%), without difference between the two techniques. Embolic events were encountered postoperatively in four (15%) and 16 (48%) patients having eversion and standard CEA, respectively (p< 0.02). Four patients developed new neurological symptoms equally distributed between eversion and standard CEA. Two (3%) deficits were permanent and two transient. The patency of the carotid bifurcation was confirmed in all instances with duplex scanning.CONCLUSIONwe identified a surprisingly high number of postoperative embolic events as detected with transcranial Doppler in patients who had undergone carotid surgery using standard endarterectomy, as compared to patients who underwent eversion endarterectomy. Whether this difference has any clinical implication has yet to be proved.

Objectives: To evaluate the fate of perianeurysmal fibrosis (PF) following aneurysm surgery.Methods: In this single centre study, pre- and postoperative abdominal CT-scans on 21 consecutive patients with inflammatory abdominal aortic aneurysms were compared. CT-scans of 10 randomly chosen patients operated on for abdominal aortic aneurysms without PF in the same period, served as reference group.Results: Preoperative thickness of PF was assessed as > 1 cm in 11 and < 1 cm in 10 patients. Ureterolysis was performed in seven patients where the fibrosis caused ureteral obstruction. Postoperative CT-scans performed at a median of 24 (range 3-108) months after surgery showed complete regression of the fibrosis in 29%, partial regression in 57% and no change in 14% of the patients. Progression of the fibrosis or persistence of hydronephrosis was not seen. No sign of fibrosis were seen in the 10 controls.Conclusion: This study supports the findings that PF tends to regress.

The results of 101 in situ by-pass operations to the ankle and foot are given. Seventy-five percent of the patients had other arteriosclerotic manifestations and 55% were diabetics. Ninety-nine percent of the operations were limb salvage surgery. The accumulative secondary patency rate was 87% after one month and 65% after three years. The results did not differ from by-pass surgery to the crural arteries. The wound complication rate was 16% with an infection rate of 7% and the major amputation rate was 8% after one month and 10% after three years. The survival of this selected group of patients was lower than a group of sex- and age-matched controls. The long term results of this type of advanced by-pass surgery in limb threatening ischaemia are very satisfactory and should be a must in every vascular surgeon's armamentarium.

Clinical implications of vascular graft infection vary according to the position of the implanted graft. The infected aortic bifurcation graft is associated with a high incidence of therapeutic failure and also a high mortality rate. 1-s In comparison, the mortality rate is low following infection of an infrainguinal bypass graft, but the risk of major amputation approaches 80%. 6'7 The close anatomical relation to the perineal area and the poor vascularisation of the subcutaneous tissue combined with a rich regional lymphatic supply predispose the groin to wound infection. Thus, not only local contamination, but also haematogenous and lymphogenic spread from other infectious sites may contribute to the high incidence of infectious complications in the groin. According to Herbst et al. s one out of three graft infections is caused by microorganisms originating from the patient's ischaemic ulcer, corroborating the observation by Lorentzen et al} that 20% of foot ulcers yield the same microorganism as isolated from the graft. Management of infected vascular prostheses is controversial. One approach is to remove the graft with a new extra-anatomic arterial reconstruction in one or two proceduresg; but it is associated with a high level of complications and bears a high mortality, especially with the involvement of an aortobifemoral graft, s'1°'1~ The other approach involves less extensive procedures in combination with administration of potent antibiotics.S,6,12 ~5 With this approach excellent results have been reported even in patients with aortic graft sepsis} 6 One such antibiotic is gentamicin applied to the region of the infection, e.g. the groin. 12'13 In our first reports on this treatment, results from 14 and 17 patients, respectively, were presented. 12'~3 In this report the number of patients has increased to 38 with a follow-up period of up to 6 years, mean 13 months.

Objective: To investigate the effect of a 3 day perioperative iloprost regimen on the patency of femorodistal bypass grafts. Design: Prospective, randomised, placebo-controlled study. Setting: Twenty-one specialised vascular surgical centres in Northern Europe. Subjects and treatments: Preoperatively 528 patients undergoing femorodistal bypass surgery were randomised to receive either iloprost or placebo intravenously at the beginning of the operation and in three daily 6 h infusions postoperatively with an intragraft injection given on completion of the bypass procedure. Chief outcome measures: Patency, surgical interventions and clinical outcome were recorded in all cases for 12 months after bypass. Results: Five hundred and seventeen patients received a bypass as planned and were evaluable. The graft material was vein in 424 cases (82%) and prosthetic or partly prosthetic in 92 (18%). Overall primary patency rates at 12 months were 52.0% for vein grafts and 45.1% for prosthetic grafts (p = 0.25). The effect of iloprost on primary patency was not statistically significant at 12 months in either vein or prosthetic grafts, but an early effect of improved patency in prosthetic grafts was seen over the first 3 days. Other results at the end of follow-up were similar in both treatments groups: 105 patients (20.3%) had been amputated, a further 85(16.4%) had died and 78 (15.1%) were still suffering from rest pain or trophic lesions. Two hundred and thirty-eight patients (46.0%) were alive with both legs and either no symptoms or only intermittent claudication after 12 months. Conclusions: In the setting of this multicentre trial no long-term benefits from the use of a 3 day iloprost regimen were demonstrated Surprisingly small differences were found between the outcomes of vein and prosthetic femorodistal bypass grafts.

Percutaneous transluminal angioplasty (PTA) has become an established treatment modality for iliac artery stenosis. PTA of iliac artery occlusions, however, remains a topic of controversy due to difficulties with mechanical recanalization, a lower patency rate and a higher complication rate than obtained after PTA of iliac artery stenosis. During a three year period, we performed 31 PTA's of iliac artery occlusions. The primary recanalization rate was 71% (22 occlusions). Stents were applied in 16 patients. The cumulated patency rates were 95% and 85% after one and six months respectively. There was one late reocclusion after two years. We found a tendency towards inferior patency in the longer occlusions (> or = 5cm). The complication rate was 10% due to three episodes of distal embolisation, all of which were successfully treated immediately with additional PTA and stenting. These results are in accordance with the results of international studies, and suggest that PTA is a useful alternative to surgical treatment of iliac artery occlusions, albeit long occlusions involving both the common and the external iliac artery should be excluded.

Karbase, a Danish register for vascular surgery is presented with data from four years experience. The register consists of 65 variables centered on risk factors, the perioperative course as well as follow-up information. During the four-year period 1989-1992 a total of 4902 admissions were registered in 3810 patients. Surgery was performed during 4005 admissions. Output data from Karbase is presented with results on survival and postoperative complications, related to preoperative risk factors. The incidence of surgical wound infections was 3.9%, with a significant reduction during the years (p = 0.004). Karbase is now used by all vascular surgical units in Denmark. We conclude that the establishment of a continuous registration has been beneficial to the department. We have achieved valid data on treatment, outcome and complications in relation to individual risk factors. In the future the use of Karbase will be extended with the aim of further quality development, locally as well as nation wide.

Le but de ce travail etait d'identifier les malades necessitant un sejour prolonge (plus de 48 heures) en unite de soins intensifs (USI) apres cure chirurgicale d'un anevrysme de l'aorte abdominale (AAA) et d'evaluer l'influence des complications peri-operatoires sur la survie et la qualite de vie a court et a long terme. Sur 553 malades operes d'un AAA, 51 (9 %) sont decedes au cours des 48 premieres heures. Parmi les 502 malades ayant survecu plus de 48 heures, 109 necessiterent un sejour en USI de plus de 48 heures, ce sejour etant inferieur a 48 heures chez 393 malades. La repartition des facteurs de risque pre-operatoires etait analogue dans les deux groupes

Materials: 54 women and 36 men, aged 56 (median; range: 34–78 years) underwent 109 consecutive mesenteric reconstructions. The indication in 90 primary procedures was acute mesenteric ischaemia of non-embolic origin in 25 patients, chronic ischaemia in 53 and prophylactic reconstruction in connection with aortic surgery in 12 patients. The superior mesenteric artery (SMA) was revascularised in 87 patients and the coeliac axis or common hepatic artery in six. Thus, only three patients had both territories revascularised. Thromboendarterectomy was performed in 15 patients, transposition of the SMA directly into the infrarenal aorta in 30 and bypass in 48 patients. Chief outcome measures: Cumulative symptom-free and survival rates. Main results: The overall perioperative (30 days) mortality rate was 13%, mainly caused by the high mortality rate of 44% (11 patients) in the acutely operated, as the mortality was 0% in patients operated on electively and only one out of 12 patients (8%) died after a prophylactic operation. Nine of the twelve deaths were due to progressive mesenteric infarction. Cumulated survival rates were 81, 60 and 35% after 5, 10 and 20 years, respectively which indicated a mortality rate three times that of an age- and sex-matched Danish population. During follow-up symptoms recurred in 30 patients, more often following emergency surgery and SMA transposition. Conclusions: Mesenteric revascularisation may yield long lasting results. However, surgery for acute ischaemia carries a high mortality rate, emphasising the importance of early surgery.

During a 10 year period 58 patients with renovascular hypertension due to renal artery stenosis were treated surgically. A retrospective analysis of the results was carried out. No perioperative mortalities occurred. Ten percent of the patients developed hypertension again after an average of 27 months. At follow-up (median 65 months), 85% of the patients had normal blood pressure or either no, modest or considerably reduced anti-hypertensive medication. It is concluded that surgical treatment of renovascular hypertension is a safe and effective procedure.

The purpose of the study was to evaluate the effect of surgery for renal artery stenosis in patients with impaired renal function. The design was a retrospective investigation with follow-up. The material consisted of 42 such patients operated at Rigshospitalet between 1980 and 1990. Renal function and blood pressure status was evaluated preoperatively and at follow-up. The perioperative mortality was 5% (n = 2) and morbidity 21% (n = 9). At discharge from hospital renal function was maintained in 38 patients (90%), including three patients who at the time of operation were without diuresis and had been in dialysis for up to 28 days. Twenty-three patients were still alive at postoperative follow-up at a median of 66 months. The cumulative five-year survival was 62%, which was significantly lower than that of a sex- and age-matched population. Eleven patients developed terminal renal insufficiency during the follow-up period. The cumulative preservation of renal function was 77% after five years. In conclusion, reconstruction of the renal arteries in patients with declining renal function and renal artery stenosis or occlusion can save renal function such that dialysis may be avoided in most cases.

During a ten-year period 735 patients with abdominal aortic aneurysm were admitted of whom 656 patients were operated on. The perioperative mortality was 18%: 5% in cases electively operated on, 17% in acute not ruptured cases, and 37% in patients presenting with rupture. Age significantly affected perioperative (< 31 days) mortality-both considered alone and assessed together with other risk factors. Further analysis indicated that the perioperative mortality of octogenarians did not differ from the mortality of septuagenarians, who on the other hand experienced a perioperative mortality rate twice that of patients younger than seventy years. Survival beyond the perioperative period was adversely affected only by age and ischemic heart disease.

From 1986 through to 1990 a total of 483 in situ bypass procedures were performed in 444 patients. Preoperative risk-factors were equally distributed among diabetic (DM) and non-diabetic (NDM) patients, except for smoking habits (DM:48%, NDM:64%, p = 0.002) and cardiac disease (DM:45%, NDM:29%, p = 0.005). Critical limb-ischaemia was more often present in diabetic than non-diabetic patients (DM:57%, NDM:36%, p = 0.0002). Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.00001). There were no differences among diabetic and non-diabetic patients regarding three years primary and secondary patency (58% and 64% respectively), and regarding major amputations. However, the rate of minor amputations was higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetics (p < 0.00001). A markedly decreased survival rate was found in diabetics (p < 0.00005). We found the in situ bypass technique very useful in the treatment of critical ischaemia of the lower limb in diabetic patients. The overall results in diabetic patients, whether insulin-dependent or not, were equal to those in non-diabetic patients.

In situ saphenous vein arterial bypass flow was studied in 16 patients with respect to level of epidural anaesthesia. Arterial pressure and electromagnetic flow were used to evaluate arterial tone by intra‐arterial (i.a.) papaverine. Eight patients had a low epidural block (Th. 10) and eight patients were operated during high epidural anaesthesia (>Th. 10). Flow increased and arterial pressure decreased after i.a. papaverine in all patients. When compared with patients operated during high epidural anaesthesia, flow increase and decrease in vascular resistance took place in patients operated during low epidural anaesthesia (P<0.02). Increase in arterial flow after i.a. papaverine was not significantly different in patients operated in low epidural and general anaesthesia (n = 8). In eight patients with insulin‐dependent diabetes mellitus who had low epidural anaesthesia, the increase in flow after i.a. papaverine was not significantly different to that noted during high epidural anaesthesia. The results indicate that the level of analgesia influences graft flow after i.a. papaverine, probably reflecting differences in the effect of epidural anaesthesia on sympathetic tone to the leg.