Objectives Percutaneous dialysis access interventions are routinely used to maintain the patency of dialysis access despite the lack of data regarding their long-term effectiveness. This retrospective study was undertaken to study the effectiveness and safety of percutaneous dialysis access interventions in arm fistulas and bridge grafts in an office-based endovascular center. Methods Patients who had a percutaneous dialysis access intervention in their upper extremity access site, performed at a single office-based endovascular center over a nine-year period (2007–2016) were included in this study. The patients’ demographic factors, patency, and complications were analyzed. Patients were entered in the study after first percutaneous dialysis access intervention. Results A total of 298 limbs in 259 patients had 913 procedures carried out over a nine-year period. There were 190 access arteriovenous fistulas and 108 arteriovenous grafts. The two most common arteriovenous fistulas were the brachiocephalic fistula (n = 74, 39%) and radio cephalic fistula (n = 69, 36%). Arteriovenous grafts were most commonly placed in the upper arm (n = 66, 61%) followed by the forearm (n = 42, 39%). The mean overall patency for all limbs was 50.86 months. Arteriovenous fistulas had a significantly longer patency than arteriovenous grafts (51.65 vs. 42.09 months; P = 0.01). In addition, patients with two or more percutaneous dialysis access intervention in their arteriovenous fistula had significantly greater patency than those with only one percutaneous dialysis access intervention (58.5 vs. 7.6 months; hazard ratio 0.41; P = 0.0008). This was not true for the arteriovenous graft group. Women represented 49% of the patient group. Their accesses had shorter patency than men (39.8 vs. 60 months; P = 0.0007). Conclusions This data support the use of repeated percutaneous dialysis access intervention to maintain long-term patency of dialysis access sites in an office-based endovascular center. Overall, fistulas have longer patency than grafts and women have poorer outcomes as compared to men

Objective: We evaluated the outcomes and complications of transcarotid artery revascularization (TCAR) outside of academic vascular surgery programs. Methods: An institutional review boardeapproved retrospective study was performed. Data from all cases of TCAR performed at a community hospital from May 2017 to February 2020 were collected and analyzed. Seven vascular surgeons performed the procedures after receiving appropriate training. The primary outcomes included technical success, the need for further revascularization, and major adverse events (death, cerebrovascular accident [CVA], myocardial infarction). The secondary outcomes included other adverse events and complications. The outcomes were assessed in the perioperative and 30-day follow-up periods. Results: During a 33-month period, TCAR was completed in 147 of 149 attempted cases (98.7%). No patients required further revascularization. The perioperative and 30-day major adverse event rates were 0.7% (n = 1) and 3.4% (n = 5), respectively. One case of aminor perioperative CVA occurred. At 30 days, one patient had died. The 30-day complications included CVA (n = 1) and myocardial infarction (n = 3). The combined perioperative and 30-day minor complication rates were 2.7% and 1.4%, respectively. Conclusions: TCAR is a safe and effective method of carotid artery revascularization in a community hospital setting. This technology might help improve revascularization in patients without access to larger academic centers.

BACKGROUND:The Food and Drug Administration recommends that retrievable inferior vena cava filters (IVCFs) be removed 29-54 days postinsertion. Nationally, the retrieval rate is around 23-25%. The objectives of this study are to assess the effect of a plan for IVCF retrieval and access to an office endovascular center (OEC) on filter removal rates and to assess the safety of the procedure in an OEC. METHODS:In this institutional review board-exempt retrospective study, the medical records of all patients who had an IVCF placed or removed in the hospital and OEC setting by one group of vascular surgeons between January 2011 and February 2017 were analyzed. Informed consent was not required for this retrospective chart review. The following data were abstracted: filter model, procedure site, retrieval plan, number of removal attempts, complications attributed to removal, success of removal, and the duration that the filter was in place. Anticoagulation was not discontinued before filter retrieval. Filters were removed under local anesthesia with or without mild conscious sedation. RESULTS:IVCF removal was attempted in all eligible patients, 120 of 191 with IVCFs, whereas 71 patients were lost to follow-up (46), died (19), or the indication changed (6). Of the patients who had filters placed in the hospital (n = 161), 62% were removed (n = 101), of which 86% had a removal attempt in the OEC, whereas 14% had the filter removed in the hospital. Sixty-three percent of patients who had filters placed in the OEC (n = 30) had the filter removed in the OEC (n = 19). All patients with a newly placed filter were given an office appointment with a vascular surgeon for evaluation and removal planning. Of patients who had their filter removed at the OEC, all were removed via the jugular approach, resulting in 103 of 106 (97%) successful removals in the OEC. Visipaque (GE Healthcare, Chicago, IL) contrast was used during filter removal. Intravascular ultrasound was not used because the study predates the insurance coverage of this technology in the office laboratory. There was no mortality related to filter removal. In addition, there were no bleeding complications, despite patients remaining on anticoagulant therapy during the removal. In 4% of patients, the filter was removed in less than 3 weeks, 30% of patients between 3 and 6 weeks, 26% of patients between 6 weeks and 3 months, and 40% of patients after 3 months. CONCLUSIONS:Having access to both an OEC and a documented retrieval plan increases the frequency of IVCF removal in a community compared with national rates. Retrievable filters can be safely removed in an OEC with extremely high success and safety. Anticoagulation therapy can be continued during retrieval attempt without increased risk of bleeding.

Objective: To evaluate the safety and effectiveness of infrainguinal artery revascularization via atherectomy supplemented with other endovascular techniques in an office endovascular center (OEC) setting. Methods: A retrospective study was conducted examining 352 lower extremity atherectomy revascularization procedures between 2011 and 2016 at an OEC by five board-certified vascular surgeons. Patients received laser atherectomy or orbital atherectomy followed by angioplasty or angioplasty and stent placement as needed. Reintervention was indicated based on evidence of clinical symptoms and imaging studies. Demographics, vessel-specific data, treatment information, and outcome of procedures were recorded. Data analysis was carried out using Kaplan-Meier survival curves. Results: Lower extremity atherectomy was carried out in 282 patients in 352 limbs with average age of 69 +/- 11 years. Technical success of <30% residual stenosis by angiogram was achieved in 571/594 vessels treated. Within 30 days of procedure, 23/352 limbs required major amputation resulting from pre-existing disease, ranging from 3 Rutherford class 4, 17 Rutherford class 5, to 3 Rutherford class 6 limbs. No 30-day mortality was noted. The primary patency of the 571 treated vessels at 12 months was 90%, and 84% at 29 months. The patency of treated vessels that reached >50% stenosis on follow-up and required reintervention (51/571 vessels) or did not require reintervention (79/571) was 72% and 87% at 23 months' follow-up, respectively, with no difference in risk of occlusion identified (P = .181). There was a significantly increased risk of occlusion for vessels treated with laser atherectomy as compared with orbital atherectomy (odds ratio, 2.552; 95% confidence interval, 1.375-4.735; P=.003). No significant difference in risk of occlusion was found between treatment with atherectomy and angioplasty (466/571 vessels) compared with atherectomy, angioplasty, and stenting (102/571) with secondary patency of 90% and 85% at 6 months' follow-up, respectively. There was no difference in patency between claudicants and patients with critical limb ischemia. Conclusions: Atherectomy in conjunction with angioplasty and/or stenting has satisfactory patency with minimal complications when the procedure is carried out in an OEC. Asymptomatic >50% restenosis of treated vessels does not warrant reintervention unless the patient presents with clinical symptoms. Various atherectomy devices may result in different outcomes.

OBJECTIVE:The objective of this study was to evaluate the safety and efficacy of a retrograde tibial approach in revascularization of lower extremities for treatment of ischemia in anatomically challenging patients. METHODS:This is a retrospective study of 57 procedures performed between 2012 and 2016 using the retrograde approach to treat patients with flush occlusion, inability to cross the lesion, failed bypass, or hostile groin. Demographic data, Rutherford classes, vessels treated, and approach were noted. Type of procedure, complications, amputations, deaths, and patency of access tibial vessels and treated vessels were recorded. Ultrasound-guided tibial access was achieved through the anterior tibial artery, posterior tibial artery, or peroneal artery. Technical success was defined as residual stenosis of <30%. Restenosis was defined as two times increase in velocity at the site of treatment. In follow-up, access vessel patency and treated vessel patency were evaluated by physical examination and ultrasound. Kaplan-Meier survival curves were used to assess proportional hazards before using the marginal Cox model to determine statistical significance in risk of postintervention occlusion. RESULTS:In 53 patients (32 men) with an average age of 67 ± 10.6 years, Rutherford categories were as follows: class 2, n = 1; class 3, n = 37; class 4, n = 5; class 5, n = 12; and class 6, n = 2. Tibial arteries were successfully accessed in all limbs. Lesions were crossed in 56 of 57 limbs. One procedure was terminated because of local arterial dissection. Revascularization was achieved in 55 of 57 limbs. Within 30 days of the procedure, 2 of 2 Rutherford class 6 patients and 1 of 12 class 5 patients needed major amputation because of pre-existing disease. There was no 30-day mortality. Of 103 vessels treated, technical success was achieved in 97 (94%). Secondary patency for 103 vessels was 79% with mean follow-up of 6.66 ± 5.4 months. The primary patency was 90% compared with a primary assisted patency of 51%. There was no statistically significant difference in access vessel primary patency in follow-up: 86% (30/35) for anterior tibial artery, 80% (16/20) for posterior tibial artery, and 100% (2/2) for peroneal artery. In addition, in follow-up, there was no significant difference in incidence of occlusion of target vessels based on choice of access vessel used (P = .109). CONCLUSIONS:In this group of anatomically challenging patients, a retrograde tibial approach was safely used. Accessing the tibial artery does not usually cause access vessel occlusion and resulted in no adverse outcomes. The majority of access vessels remained patent for future bypass if necessary.

The Food and Drug Administration recommends that retrievable inferior vena cava filters (IVCF) be removed between 25 and 54 days post insertion. Nationally, the retrieval rate is abysmally low. The objectives of this study are to (1) assess if a retrieval plan and access to an office endovascular center (OEC) will increase retrieval rates, and (2) assess the safety of the procedure in an OEC. In this institution review board-approved retrospective study, the medical records of patients who had an IVCF placed and/or removed in the hospital and OEC setting between January 2011 and January 2017 were analyzed. Demographic data collected include: hypercoagulable status, indication for insertion, point of entry, filter model, procedure site, documented retrieval plan, number of removal attempts, point of entry for removal, complications attributed to removal, success of removal, and the duration that the filter was in place. Anticoagulation was continued before filter retrieval. Filters were removed under local anesthesia or mild conscious sedation. IVCF retrieval was attempted in 116 of 214 patients, while the rest were lost to follow-up, died, or the indication changed. Of the patients who had filters placed in the hospital, 76% (n = 83) had a removal attempt in the OEC, while 14% had the filter removed in the hospital. Patients who had IVCFs inserted in an OEC had their filters removed in the OEC only. A documented retrieval plan was found in the medical record of 95% of patients. All filters were removed via the jugular approach, resulting in 99 of 101 successful removals (98%) in the OEC. There was no mortality related to filter removal. Additionally, there were no bleeding complications, despite the fact that patients remained on anticoagulant therapy during the removal. In 4% of patients, the filter was removed in less than 3 weeks, 29% of patients between 3 and 6 weeks, 26% of patients between 6 weeks and 3 months, and 40% of patients after 3 months. The most common filter removed was the Celect Cook (42.3%), followed by Eclipse Bard (18.8%), and Denali Bard (17.9%). Various other filters made up the remaining 21% (Fig). The incidence of removal of retrievable filters improves with a well-documented removal plan. Access to an OEC further helps increase the frequency of removal because of ease of access. Furthermore, retrievable filters can be safely removed in an OEC with extremely high success rates (98%). Finally, anticoagulation therapy can be continued during retrieval attempt without untoward complications.

This study evaluated the safety and efficacy of retrograde tibial approach in revascularization of lower extremity for treating ischemia in anatomically challenging patients. In this Institutional Review Board-approved retrospective study, 56 patients underwent 60 procedures between 2012 and 2016, during which 112 vessels were treated using a retrograde approach due to flush occlusion, inability to cross lesion, failed bypass, or hostile groin. Demographic data, Rutherford classes, vessels treated, and vessel approach were noted. Type of procedure, complications, amputations, deaths, and patency of access tibial vessels and treated vessels were recorded. Technical success was defined as residual stenosis of <50%. Restenosis was defined as a two-times increase in velocity at the site of treatment. In follow-up, access and treated vessel patency were evaluated by physical examination and ultrasound imaging. Life-table analysis was performed. The χ2 test was used to test relations between risk factors and occlusion. There were 56 patients (34 males). Average age was 67 ± 11.3 years. Rutherford categories were class II (n = 1), class III (n = 39), class IV (n = 5), class V (n = 13), and class VI (n = 2). The lesion was crossed in 59 of 60 limbs. One procedure was halted due to local dissection. Within 30 days of procedure, two of two Rutherford class VI and one of 13 class V patients needed major amputation. There was no 30-day mortality. Technical success occurred in 105 of 112 vessels (93.8%). In follow-up, overall patency for 112 vessels at 19 months was 53.98%, 83 of 112 vessels (74.1%) not requiring secondary intervention had a patency of 75.4% at 19 months, and 29 of 112 vessels (25.9%) needing reintervention had a patency of 20.3% at 17 months (Fig 1). During follow-up, 32 of 37 (86.5%) of the AT, 19 of 21 (90.5%) of PT, and 2 of 2 (100%) of peroneal access vessels remained patent. Effect of various factors on vessel outcome is listed in the Table. In this anatomically challenging patient group, the tibial approach can be safely used with good medium term results. The retrograde approach rarely causes access vessel occlusion and results in no adverse outcome. Access vessel is not compromised for future bypass. Patients in Rutherford class II to III do better than those in IV to VI. Postprocedure anticoagulant treatment, excluding clopidogrel and warfarin, has a beneficial effect in improving follow-up patency.TableEffect of various factors on target vessel occlusion post interventionFactorsOR (95% CI)P valueRutherford Group (II-III vs IV-VI)2.94 (1.32-6.67).008Antiplatelet pre-op2.27 (0.92-5.59).07Antiplatelet post-op1.09 (0.44-2.68).86Warfarin pre-op0.53 (0.11-2.50).89Warfarin post-op0.35 (0.06-1.99).95Clopidogrel pre-op1.34 (0.57-3.14).50Clopidogrel post-op2.07 (0.81-5.28).12Other anticoagulants pre-op0.72 (0.17-3.04).79Other anticoagulants post-op0.14 (0.04-0.54).002aCI, Confidence interval; OR, odds ratio.aStatistically significant. Open table in a new tab

This study determined the safety and efficacy of infrainguinal artery atherectomy. In this Institutional Review Board-approved retrospective study, 260 patients underwent orbital or laser atherectomy on 362 limbs in 615 vessels between 2011 and 2016. Demographic data, Rutherford class, vessels treated, vessel approach, and type of device used were noted. Success and type of procedure, complications, 30-day major amputations, and deaths were recorded. Technical success was defined as <50% stenosis. Restenosis was defined as a two-times increase in velocity at the treated site. In follow-up, vessel patency was evaluated by examination and ultrasound imaging. Technical success was defined by residual stenosis <50%. Symptomatic patients with restenosis of >50% underwent reintervention, and asymptomatic patients did not undergo reintervention. Life-table analyses were performed. The χ2 test was used to test relations between risk factors and occlusion. Rutherford class distribution was 2 (n = 8), 3 (n = 166), 4 (n = 41), 5 (n = 103), and 6 (n = 11). There were 23 major amputations on 362 limbs (6%) in Rutherford class 4 (3 of 41), 5 (17 of 103), and 6 (3 of 11). Mortality was 0. Complications included perforation in 3, abrupt closure in 2, and embolization in 1. Technical success was 604 of 615 vessels (98%). By atherectomy device, orbital (n = 515) patency was 91% (mean follow-up, 29 ± 31 months) and significantly better than laser (n = 100) patency at 78% (mean follow-up, 33 ± 32 months). Previous bypass had a significant negative impact (P = .04). Preoperative clopidogrel (P = .04) or preoperative (P = .01) and postoperative (P = .003) anticoagulants had a significant salutary effect. Patency after angioplasty was 89% in 498 vessels, with a mean follow-up of 31 ± 31 months. Patency in 106 vessels treated with angioplasty and stent was 86%, with a mean follow–up of 23 ± 29 months. After secondary intervention, vessels had lower patency (Fig 1). Patients with >50% stenosis who had secondary intervention had worse results than patients who did not (Fig 2). In medium-term follow-up, excellent patency is achieved using atherectomy and angioplasty with minimal complications. Asymptomatic restenosis of >50% does not warrant reintervention. These procedures have comparable results among various Rutherford classes. Use of anticoagulants is beneficial. Various atherectomy devices may result in different outcomes.Fig 2Kaplan-Meier curves for vessel survival by patency group starting at 50% stenosis. Stenosis >50% developed in 143 vessels (23.3%); of those, 91 (64%) had no intervention and a 96% patency at a mean follow-up 30 ± 28 months. Fifty-two (36%) received reintervention and had a patency of 67%, with a mean follow-up of 35 ± 33 months.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Radial artery access for percutaneous interventions was first introduced in 1989 for diagnostic coronary angiography. Radial access is being used in about 2% of peripheral percutaneous cases nationally, while femoral approach remains the preferred method. We present our experience with radial artery access for diagnosis of peripheral artery disease and intervention in our office endovascular lab.

Objective: This study was conducted to identify the safety of endovascular procedures in the office endovascular suite and to assess patient satisfaction in this setting.Methods: Between May 22, 2007, and December 31, 2012, 2822 patients underwent 6458 percutaneous procedures in an office-based endovascular suite. Demographics of the patients, complications, hospital transfers, and 30-day mortality were documented in a prospective manner. Follow-up calls were made, and a satisfaction survey was conducted. Almost all dialysis procedures were done under local anesthesia and peripheral arterial procedures under conscious sedation. All patients, except those undergoing catheter removals, received hydrocodone and acetaminophen (5/325 mg), diazepam (5-10 mg), and one dose of an oral antibiotic preprocedure and three doses postprocedure. Patients who required conscious sedation received fentanyl and midazolam. Conscious sedation was used almost exclusively in patients having an arterial procedure. Measurements of blood urea nitrogen, creatinine, international normalized ratio, and partial thromboplastin time were performed before peripheral arteriograms. All other patients had no preoperative laboratory tests. Patients considered high risk (American Society of Anesthesiologists Physical Status Classification 4), those who could not tolerate the procedure with mild to moderate conscious sedation, patients with a previous bad experience, or patients who weighed >400 pounds were not candidates for office based procedures.Results: There were 54 total complications (0.8%): venous, 2.2%; aortogram without interventions, 1%; aortogram with interventions, 2.7%; fistulogram, 0.5%; catheters, 0.3%; and venous filter-related, 2%. Twenty-six patients required hospital transfer from the office. Ten patients needed an operative intervention because of a complication. No procedure-related deaths occurred. There were 18 deaths in a 30-day period. Of patients surveyed, 99% indicated that they would come back to the office for needed procedures.Conclusions: When appropriately screened, almost all peripheral interventions can be performed in the office with minimal complications. For dialysis patients, outpatient intervention has a very low complication rate and is the mainstay of treatment to keep the dialysis access patent. Venous insufficiency, when managed in the office setting, also has a low complication rate. Office-based procedural settings should be seriously considered for percutaneous interventions for arterial, venous, and dialysis-related procedures.

With the advent of endovascular techniques thrombectomy of occluded dialysis graft can be carried out percutaneously. Over the last few years various devices have been approved for mechanical thrombectomy of dialysis graft. We describe a technique that we have developed without using these devices, in our office based endovascular suite. Patient is given hydrocodone 5 mg, Diazepam 5 mg and Cefazolin 500 mg orally before the procedure. Patient is not fasting. After prepping and draping the extremity Xylocaine 1% is infiltrated in the skin. Crossing micro puncture needles are introduced into the graft pointing towards each anastomosis. Guide wires are threaded through the needles. Needles are removed and micro puncture sheaths are threaded over the guide wires. Fistulogram is done to confirm the thrombosis and to make sure the catheters are in the lumen. Two ml of tissue plasminogen activator is introduced through each catheter. After 15 minutes glide wires are threaded through each sheath and these are switched to 6 French sheaths. The glidewires should cross both anastomoses. Five French embolectomy catheter is threaded over the arterial wire and clot is pulled out of the arterial side and flushed out of the side port of the sheath. Same procedure is carried out on venous side. Fistulogram is performed and the procedure is repeated until there is no residual clot. Invariably there is stenosis present at the graft vein anastomosis or in the graft circuit. Rarely there is arterial stenosis. If it is a 6mm graft 8mm balloon is used to dilate the area of stenosis at the graft vein anastomosis. The sheaths and guide wires are removed and puncture sites are closed with nylon suture. the graft can be used immediately. A similar procedure can be used for a fistula.

After the fellowship in vascular surgery is completed there is the daunting task of going into practice and succeeding. There are various tools that one can use to succeed in practice and also work closely with other specialists. The key to success is marketing and innovation. Using the two together any vascular surgeon can succeed. Marketing has multiple facets not to be confused with advertising. Total marketing revolves around the surgeon. It involves personal attributes, running of the office, behavior in the hospital, working with other physicians, and using advertising channels. Innovation is required as the art and science of the specialty continues to evolve. Vascular surgeons need to be on the cutting edge of providing latest technology as well as latest methods of delivering care.

OBJECTIVE:The practice of vascular surgery is under pressure from various specialties and payers. Our group started office-based procedures in May 2007. This article reports our study of the effect of this change on our case volume, office revenue, and the financial impact on the health care system. METHODS:Between May 1, 2006, and April 30, 2007 (period 1), and between June 1, 2007, and May 31 2008 (period 2), 3041 and 3351 cases, respectively, were performed. In period 1, only venous cases could be done in the office. Before arteriogram, serum levels of urea nitrogen and creatinine were obtained. The number of percutaneous cases done in the hospital and office setting was analyzed, and revenue was calculated based on the 2008 Medicare fee schedule for our region. Amputation and mortality rates at 30 days were documented. Hospital DRG payment schedule was obtained. RESULTS:In period 1, 670 (22% of total) percutaneous procedures were performed compared with 1502 (44.8%) in period 2, a twofold increase. In period 1, 1.5% of total cases were done in the office compared with 31% in period 2. There was a fivefold increase in revenue from these procedures. No deaths or amputations occurred as a result of procedures performed in the office. No anesthesiologist's expense and minimal preprocedural expenses were incurred. Total payment by Medicare, DRG payment to the hospital, and the physician component were higher in all the cases. CONCLUSIONS:A vascular surgery practice can benefit from office-based procedures. Procedures can be done safely. It results in an increase in the number of percutaneous procedures and revenue with a significant savings to the health care system. Surgeons can control their schedule. Every vascular surgeon should consider doing these procedures in office.

The purpose of this study was to determine if fistulogram after prosthetic arteriovenous dialysis graft thrombectomy would reveal underlying lesions, which need correction, and if revision would improve graft patency. One hundred and ninety-two open thrombectomy procedures in 61 patients from January 1, 2000 to July 31, 2005 were reviewed retrospectively. All of the study patients were divided into two groups: In Group I fistulogram was carried out and in Group II no fistulogram was performed. Based on the fistulogram or clinical findings, appropriate intervention was carried out. In Group I, of 99 thrombectomy procedures, a significant lesion was identified and revision was carried out in 77 cases (78%). In Group II, of 93 thrombectomy procedures, a significant lesion was identified and revised in 53 cases (57%). A significant abnormality was more likely to be encountered by routine fistulogram than surgical exploration alone, 78 per cent versus 57 per cent (P < 0.05). Assisted primary patency is significantly increased in Group I and II when revision was performed (4.84 months) compared with when no fistulogram and no revision was performed (2.9 months), P < 0.05. Routine fistulogram after thrombectomy of an arteriovenous dialysis graft increases the likelihood of identifying a significant stenosis. Revision of the graft increases the longevity. We recommend routine use of fistulogram during thrombectomy.

Carotid stenting has been proposed as an alternative to reoperative carotid endarterectomy (rCEA) for recurrent carotid stenosis. The purpose of this study is to prove the safety, effectiveness and durability of reoperation in long term follow up of 18 years in a community hospital setting. From March 1988 to April 2005 80 patients, 46 men and 34 women (mean age: 64.1 years) underwent a total of 83 operations. Symptomatic recurrent stenosis (>70%) was the indication in 32, asymptomatic high-grade stenosis (>80%) in 49, intimal flap in one and fibromuscular dysplasia (F.M.D), in one. The initial operation was carotid endarterectomy with primary closure in 60 and prosthetic patch in 23. The mean recurrences were at 23.3 months in 33 with myointimal hyperplasia, 105.4 months in 29 with recurrent atherosclerosis, 61.4 months in 19 with both hyperplasia and atherosclerosis, 2 months in one with intimal flap and 8 months in one with F.M.D bands. Reoperation utilized primary closure (3), vein patch (14), prosthetic patch (55), Gore-Tex interposition grafts (7), vein interposition grafts (3) and intraoperative dilation (1). No perioperative strokes or deaths occurred. One patient died from cardiac complications following combined rCEA and coronary artery bypass grafting. Operative morbidity consisted of reversible nerve injury (5), irreversible recurrent laryngeal nerve injury (1) and hematoma requiring evacuation (3). During follow up (3-153 months; mean: 50.9) carotid occlusion resulted in mild ipsilateral stroke in one patient, and one non-hemispheric stroke. There were 26 late deaths due to all causes, one due to CVA. Eight patients required reoperation (mean 53.4 months). Seven of these were hypertensive. Kaplan-Meier analysis of long-term follow up shows relatively high stroke free rates; at 153 months (12.75 years) the hemispheric stroke free rate was 98.67% and the all-stroke free rate was 95.85%. The survival estimate following redo surgery was 69.97% at 5 years and 40.23% at 10 years. We found that individuals on statin therapy (p-value=0.0042), and those on combination of statin and aspirin (p-value=0.0320), had significantly increased interval between primary and secondary operation. Increased age was correlated to a decreased time to redo surgery (p-value=<0.0001). We conclude that reoperation for recurrent carotid stenosis using standard vascular techniques is safe, effective, durable and cost effective. It should continue to be the mainstay of treatment when secondary intervention is required. Statins have a salutary effect on durability of the procedure and should be used when indicated.

This study was conducted to determine the relative safety of early urokinase lytic therapy in expanded polytetrafluoroethylene (ePTFE) and collagen-impregnated woven velour polyester (CIWVP) grafts. Twelve mixed-breed dogs were selected and implanted with thin-wall ePTFE and CIWVP grafts in the external iliac artery position. At 3, 4, 6, and 12 weeks, three dogs were selected for lytic therapy. After exposure of the previously implanted grafts, lytic therapy was initiated with a bolus of 100,000 units of urokinase, followed by 4000 units/minute for two hours, then reduced to 2000 units/minute for a subsequent two hours. Hypertension was induced by methoxamine hydrochloride at the conclusion of lytic therapy. Direct observation and angiography were used to assess for bleeding and contrast extravasation hourly until completion. The animals were then sacrificed and the grafts excised and microscopically examined for incorporation, pseudointimal deposition, and accelerated collagen layer degradation. None of the implanted grafts showed evidence of transluminal or suture line bleeding or extravasation of contrast material. Hypertension did not change these results. Analysis demonstrated a thicker pseudointimal, giant cell infiltration, extensive incorporation, and occasional fragmentation of the CIWVP graft when compared with the ePTFE grafts. The systemic fibrinolytic state did not cause collagen layer degradation. No evidence existed of suture line or transluminal bleeding from CIWVP or ePTFE grafts during urokinase lytic therapy conducted at 3, 4, 6, or 12 weeks in a canine model. Microscopic examination demonstrated a difference in pseudointima, graft incorporation, and inflammatory response when the two conduits were compared. Urokinase did not appear to accelerate collagen layer breakdown.

BACKGROUND:The aim of this study was to evaluate the efficiency of thrombolysis in the presence of an occluded femoropopliteal synthetic graft. PATIENTS AND METHODS:Over a 3-year period, 46 occluded femoropopliteral grafts were treated with urokinase and reconstruction. The cases were divided into three groups: group 1 (n=25), complete thrombolysis followed by reconstruction or angioplasty or both; group 2 (n=5), complete thrombolysis alone; and group 3 (n=16), failure of thrombolysis requiring reconstruction or leading to amputation. Patients were completely observed after treatment for more than 1 year. RESULTS:There are no fatal complications among patients with thrombolytic therapy. In group 1, the 3-year patency rates were 12% and the 3-year limb salvage rates were 77%. In group 2, the 3-year patency rates and the limb salvage rates were 20% and 80%, respectively. The group 3 patency rates and the limb salvage were 8% and 40%, respectively. The best results were achieved in patients who had thrombolysis followed by reconstruction (group 1) and in those who had thrombolysis alone (group 2). limb salvage was poor in patients with failure of lytic therapy regardless of the reconstruction (P<0.01). CONCLUSION:The use of intra-arterial urokinase followed by secondary vascular reconstructive procedures was studied. The patient with synthetic graft occlusion still has a reasonably favorable prognosis for long-term limb salvage when thrombolysis is successful.

The objective of this study was to evaluate the relation between runoff vessels and the prognosis in patients who have had an occlusion of a previously placed peripheral arterial bypass graft. Over a 4-year period 77 occluded synthetic grafts were treated with urokinase and reconstruction after angiographic study. Follow-up ranged from 1 to 1627 days. The cases were divided into three groups according to the number of patent tibial vessels. Group I consisted of patients who had no vessel runoff. Group II consisted of patients who had single vessel runoff. Group III consisted of patients who had two or three runoff vessels. In Group I, the 1, 2, and 3-year patency rates were 35.8%, 8.9%, and 8.9%; and the limb salvage rates were 50.2%, 40.2%, and 40.2% for 1, 2, and 3 years, respectively. The Group II patency rates were 31.2%, 26.0%, and 13.0% and the limb salvage rates were 72.3%, 62.9%, and 62.9%. The Group III patency rates were 50.0%, 26.1%, and 20.9%; and the limb salvage rates were 93.1%, 79.1%, and 79.1%. There is no statistically significant difference in patency rates among any of the groups. The limb salvage rate was significantly increased in Group III, compared to I (P < 0.01) and Group II (P < 0.05), and in Group II, compared to Group I (P < 0.05). These results indicate that the higher rate of limb salvage in this study statistically correlated with the number of runoff vessels.

The objective of this study was to correlate the initial outcome of thrombolytic therapy in patients with specific risk factors who presented with an occluded synthetic graft. Seventy-seven angiographically documented occluded synthetic grafts were treated with urokinase. All patients presented within thirty days of occlusion. The cases were investigated according to specific risk factors: smoking (SM), hypertension (HT), coronary artery disease (CAD), and diabetes mellitus (DM). A high number of occlusions occurred in patients had a history of heavy smoking (84.4%). Complete thrombolysis was achieved in 46 of 77 (59.7%) graft occlusions. Thirty-eight of 65 (58.5%) occlusions in patients who smoked, 29 of 47 (61.7%) occlusions in patients with HT, 22 of 36 (61.1%) occlusions in patients with CAD, and 18 of 25 (72.0%) occlusions in patients with DM were completely lysed. When comparison was made between the specific risk factors, no significant difference was found in complete lysis. Forty-seven complications occurred in 31 (40.3%) of 77 cases. One patient (1.3%) suffered from a fatal intracranial hemorrhage. No significant increase in complications was seen when the various risk factors were compared. In conclusion, no relation was observed between the initial success rate with thrombolytic therapy and multiple risk factors in patients with arterial graft occlusion.