Abstract Purpose The treatment of critical limb-threatening ischemia (CLTI) is revascularization. Lumbar sympathectomy (LS) could be attempted when this is not amenable. Using laparoscopic techniques to perform LS adds the advantages of minimally invasive surgery. Methods Twenty-four patients, presenting with non-reconstructable CLTI and rest pain, were randomly divided into group I (14 patients) who underwent retroperitoneoscopic lumbar sympathectomy (RPLS) and group II (10 patients) who had conventional open lumber sympathectomy (COLS). Results RPLS patients had shorter hospital stays, fewer intraoperative complications, and less postoperative pain. However, the mean operative time was significantly longer (86.4 ± 9.1 min, p-value: 0.02) in the RPLS group but decreased with each subsequent case after that. The differences in post-operative capillary refill time, ABI, TBI, and TcPO2 were not statistically significant between both groups (p-values: 0.97, 0.13, 0.32, 0.10, respectively). However, the difference in the quality-of-life score was statistically significant; the mean (± SD) SF-36 score increased from 48 ± 6.8 to 81 ± 4.4 (p-value < 0.001) in RPLS group compared to 52 ± 8.8 to 59 ± 1.2 (p-value: 0.52) in COLS group. Conclusion RPLS is feasible, safe, and has the advantages of minimally invasive surgery: minimal blood loss, less intraoperative complications, shorter hospital stay, and less postoperative pain. However, the operative time in RPLS cases is longer than in the COLS; training on the procedure is recommended to improve the learning curve.

IntroductionIn a kidney transplant tertiary referral center; we compared three operating team configurations of different surgical specialties to highlight the effect of the operating surgeon’s specialty on various operative details and procedural outcome.Materials and MethodsA total of 50 cases of living donor transplantations were divided into three main groups according to the operating surgeons’ specialty, the first group (A) includes 12 patients exclusively operated on by urologists with advanced training in transplantation, the second group (B) includes 35 patients operated by combined surgical specialties; a urologist and a vascular surgeon both with advanced transplantation training, and a third group (C) includes 3 cases where the transplant operation commenced with operating urologists as in group (A) but required intra-operative urgent notification of a vascular surgeon to manage unexpected intraoperative technical difficulties or major complications. Cases were studied according to operative details, anastomosis techniques, ischemia times, total procedure time, recovery of urinary output, ICU (intensive care unit) stay, postoperative surgical complications and serum creatinine level for up to three years of follow-up.ResultsStudy of operative details revealed that total duration of graft ischemia was significantly shorter in group (B) and significantly longer in group (C) (P-value 0.001), Total procedural duration also varied significantly between the three groups, group (B) being the shortest while group (C) was the longest (P-value less than 0.001). Technically; group (A) used only end to end arterial anastomosis as a standard technique, while group (B) used both end-to-end and end-to-side anastomoses as required per each case. End to side anastomosis in group (B) yielded better immediate graft response in the form of change in colour , texture, earlier and more profuse postoperative urine volumes (P-value 0.025). Furthermore, anastomosis to common and external iliac arteries (group B) yielded earlier and higher urine volumes than the internal iliac artery (P-values 0.024 and 0.031 respectively). Group (B) recorded significantly less postoperative peri-graft hematomas and lymphoceles compared to the other two groups. Equal rates of urine leaks, ICU stay, creatinine levels, patient and grafts survival rates among groups (A) and (B), while post-operative recovery and ICU stay duration were more lengthy in the complicated group (C).ConclusionA vascular surgeon operating in a transplantation team would deal comfortably and efficiently with various vascular related challenges and complications, thus avoiding unnecessary time waste, complications and costs.

PURPOSE:Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI.MATERIALS AND METHODS:198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow).RESULTS:176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001).CONCLUSIONS:WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.

Background: Diabetic foot infection (DFI) is considered the most common cause of diabetes-related hospitalization. Diabetic foot ulcers are subjected to bacterial colonization with biofilm forming organisms which are difficult to eradicate. The aim of this study was to identify the spectrum of bacteria associated with DFI and their ability to form biofilm, to evaluate differences in antibiotic susceptibility pattern between planktonic and biofilm phases, and to determine the antibiotics which are active on the organism in the biofilm phase. Methods: The study comprised 50 patients with DFI. A deep swab was collected from each patient and cultured. All isolates were identified and screened for biofilm formation. Biofilm forming isolates were further subjected to minimum biofilm eradication concentration (MBEC) assays to determine resistance to different antimicrobials while in the biofilm phase. Results: Seventy-one isolates were identified, (14.1%) were Gram positive cocci, (83.1%) were Gram negative bacilli, and (2.8%) were Candida species. The most frequently isolated organism was Klebsiella spp. (18/71, 25.4%), followed by Proteus spp. (14/71, 19.7%). The prevalence of biofilm forming isolates was 38%. All the studied isolates showed MBEC higher than the MIC for all tested antimicrobials. Conclusions: The substantial discrepancy between MIC and MBEC results observed in this study emphasizes the lack of reliability of the routine antimicrobial susceptibility testing in case of biofilm formation. Among all tested antimicrobials; cefoperazone/sulbactam, gentamicin, and vancomycin demonstrated activity against bacteria in the biofilm phase.

Objective Investigating the early results of percutaneous transluminal angioplasty of chronic lower-limb ischemia in patients with chronic renal failure. Background The concern that endovascular treatment of chronic lower-limb ischemia in patients with chronic renal failure is gaining popularity nowadays since the increase in morbidity and mortality rates in bypass surgery makes the procedure difficult for these patients. Patients and methods In total, 40 limbs in 40 consecutive patients (28 male, mean +/- SD age 59.65 +/- 8.54) were analyzed, 28 with lesion, either gangrene or ulcer, and 12 with rest pain. The follow-up of healing and foot vascularity was done at regular periods and up to 1 year as ABI was not a good indicator for follow-up because of the high false results due to severe calcification. Results After 12 months, the end results of the study are as the following: 10 (25%) cases were relieved from rest pain, another 12 (30%) cases had healed lesion, and three (7.5%) cases had major amputation, 11 (27.5%) cases had return of the same complaint as preoperative by the end of 12 months. Conclusion Despite improvement in endovascular techniques and their increasing utilization for lower-extremity revascularization, peripheral revascularization in chronic renal-failure patients has not led to high limb-salvage rate. Poor outcomes may be related to the severity of ischemia on presentation, the cumulative burden of the atherosclerotic disease, and the distal location of the disease.

Results: 124 patients on HD had endovascular veinoplasty. Technical success was 100% and 79% for CVS and CVO. Mean follow-up period was 36.16±12.6 months. Primary catheter site patency was 70%, 40%, 20%, and 5% after one, two, three, and four years. Assisted primary catheter site patency was 77%, 45%, 27%, and 12% and access vein survival was 100%, 80%, 40%, and 15% respectively at one, two, three, and four years, respectively.

Objectives Behcet’s disease is a multisystem disorder of unknown etiology with vascular complications. This study reviewed the mid-term outcome of Behcet’s disease patients with carotid artery pseudo-aneurysms treated by endovascular stent-graft repair at our unit. Methods During a period of 11 years, six cases were included. Postoperative ultrasound duplex results were recorded along with computed tomography angiography report done a year after intervention. Results The mean age (±SD) was 38 (±5.2) years. The mean (±SD) pseudo-aneurysm size was 33 (±12.2) mm. Technical success was 83%; failed cannulation of the internal carotid artery was encountered in one case. On day 2 post-operative, a duplex ultrasound revealed complete exclusion and thrombosis of the false aneurysm in all cases. A year later, a computed tomography angiography revealed a primary patency rate of 80%, and only one case had a recurrent pseudo-aneurysm at the distal margin of the stent graft. All cases, however, had complete thrombosis in the pseudo-aneurysms lumen with a mean (±SD) regression in size of 18 (±6) mm. The mean (±SD) percentage of in-stent stenosis was 34.5% (±11.73%). Conclusions Stent graft repair for carotid artery pseudo-aneurysm in Behcet’s disease patients might be the preferable first line of treatment since it had a high technical success and mid-term primary patency rates, with additional fact that it obviously avoids the hazardous complications of surgery.

Background: Vascular access (VA) for hemodialysis (HD) is the cornerstone of treatment of end-stage renal disease in children. Purpose:To evaluate the causes that may result in primary failures, to evaluate the long-term outcome of AVFs in the vascular access as regards primary and secondary access patency, and to study the effect of patients' demographics and type of VA upon patency.Patients and methods: Paediatric age group patients with ESRD from El Shatby University Hospital for Children were evaluated by duplex ultrasound and VA was constructed.Results: 218 children were evaluated.188children had AVF.The initial success rate was 96.8%.Early failure occurred in 13.9%.The mean follow-up was 18.9 ± 11.2 months.75% of our patients were blow 50th percentile.The mean maturation-time was 1.7±0.5 months.Primary and secondary patency rates at 1, 2, and 3 years of follow-up, were 80.1% (± 2%), 67.3% (±2%), 41.3% (±2%), and 85.4% (±1%), 75.6% (± 1%), and 67.4% (± 1%) respectively.Complications were stenosis, thrombosis, infection, venous hypertension, steal, aneurysms and pseudoaneurysm, and high-flow AVF.At the end of the follow-up period, 32 (17.3%)AVFs were complicated and eventually failed, 20 (10.8%) were abandoned due to death or patients lost follow-up, and 125 (67%) were patent. Conclusion:AVFs in paediatric age group have a good outcome and long-term patency provided by good choice of the patient, and operation by dedicated surgeons.Surveillance of the fistula and rapid correction of any complications are very crucial steps to keep the fistula functioning.

Context Management of acute limb ischemia (<14 days) has been studied in a number of prospective randomized trials, and endovascular techniques, especially thrombolysis, in high-risk patients were found to be superior than open surgery. However, owing to the better results observed in patients presenting with subacute ischemia (14 days to 3 months) treated with surgery coupled with the associated complications of thrombolysis, surgery has been the recommended treatment for these patients. Patients who present with subacute ischemia have not been well recognized in the literature. Aim The aim of this study was to evaluate the clinical and hemodynamic outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia. Settings and design A total of 22 limbs that presented with subacute leg ischemia admitted to Alexandria Main University Hospital have been studied prospectively. All patients had femoro-popliteal occlusions shown by multislice computed tomographic angiography and severe leg ischemic pain +/- crippling claudication. Patients with acute leg ischemia or extensive foot necrosis necessitating amputation were excluded from the study. Patients and methods All patients were subjected to ankle-brachial index (ABI) measurement, color duplex ultrasound (CDU) scan, and multislice computed tomographic angiography before intervention. Percutaneous transluminal angioplasty (balloon angioplasty +/- stent deployment) was performed for all participants. Clinical follow-up with ABI measurement was done at 1-, 3-, and 6-month intervals. CDU after 6 months for patency and restenosis was performed. Statistical analysis Statistical Package for the Social Sciences, version 15.0 was used. Values were compared with a paired samples t test. P values less than 0.05 were considered significant. Results Mean follow-up period was 6.2 months. The mean (+/- SD) ABI before and at 1-, 3-, and 6-month interval was 0.4 (+/- 0.2), 0.53 (+/- 0.11), 0.62 (+/- 0.12), and 0.86 (+/- 0.16), respectively, with P value less than 0.0001. Limb salvage rate for those patients who had constant ischemic pain and had primary technical success was 89%. As for those patients who had severe claudication, at 6-month follow-up, they had no complaint. Primary patency rate by CDU was 95%. Conclusions Balloon angioplasty is a safe and effective tool for management of subacute leg ischemia. It avoids high surgical risks and carries promising patency and limb salvage rates.

YY Objective: Obesity is associated with several medical problems, including chronic venous insufficiency resistant to usual conservative measures. Venous intervention in patients with a body mass index (BMI) >30 kg/m(2) is associated with a higher anesthetic risk and recurrence rate. The aim of the present study was to compare the severity of venous insufficiency in terms of the clinical findings and hemodynamics between morbidly obese patients who had and had not undergone bariatric surgery (BS). Methods: A total of 123 patients with morbid obesity and severe venous manifestations were included in the present study. The patients were divided into two groups. Group A included 72 patients who had undergone BS, and group B included 51 patients who had not undergone BS. Assessments were performed using both disease-specific and physician-generated tools and duplex ultrasonography. Results: Of the 123 patients, 66% were men. The mean patient age was 44 +/- 8.2 years. All the patients were followed up for 1 year. The mean BMI for group A had decreased from 50.1 +/- 5.6 kg/m(2) to 32.9 +/- 4.2 kg/m(2) ( P=.0001). However, the mean BMI for group B had increased from 49.2 +/- 6.1 kg/m(2) to 50 +/- 5.7 kg/m(2) ( P=.16). For the patients with a history of venous ulcer, the Charing Cross Venous Ulceration Questionnaire score for group A had decreased 77.5 to 36.8 (P=.0001) compared with a decrease in group B from 77.34 to 75.36 (P=.13). In group A, the median Venous Disability Score had improved from 2 to 0 and the median Venous Clinical Severity Score from 8.6 to 2.1 compared with nonsignificant changes in group B. The number of patients with venous claudication had decreased from 8 to 2 (P=.036) in group A compared with no changes in group B. For group A, the mean 36-item short-form heath survey score had increased from 48 +/- 6.8 to 81 +/- 4.4 ( P=.001) compared with an increase from 52 +/- 8.8 to 59 +/- 1.2 (P=.52) in group B. The mean common femoral vein diameter had decreased significantly in group A (7.3 +/- 1.3 mm) compared with that in group B (8.93 +/- 1.08; P=.0001). The peak venous velocity showed higher values for the patients who had undergone BS (group A, 14.9 +/- 2.5 cm/s; group B, 10.75 +/- 2.05 cm/s; P=.0001). Higher mean velocities and a lower diameter resulted in a higher wall shear stress in group A compared with that in group B (2.2 +/- 1.1 dyn/cm(2) vs 1.16 +/- 0.52 dyn/cm(2); P=.0001). Conclusions: The patients who had lost weight after BS experienced noticeable improvements in chronic venous insufficiency compared with the patients who had not lost weight, including an increased rate of ulcer healing, a decreased incidence of venous claudication, and improved quality of life.

Lower limb amputation (LLA) is usually performed as a life saving procedure to remove all infected, pathologic, or ischemic tissue.Irrespective of the cause of LLA, it has a significant and dramatic change in a person's life which has an effect on quality of life of patients due to the physical activity limitations immediately after amputation and long-term implications in different aspects of life.Objective: Determine the effect of a rehabilitation program on the quality of life for patients with lower limb amputation.Setting: This study was conducted in Surgical Units and Vascular Unit, Department of Surgery, Alexandria Main University and Alexandria Vascular Center (AVC).Subjects: The study subjects were included 50 adult patients with unilateral major LLA, able to communicate effectively and agreed to participate in the study.Tools: Two tools were used for data collection: Preoperative and Postoperative Lower Limb Amputation Assessment Tool and Short Form 36 (SF-36) Health Survey Questionnaire.Results: The study showed that patients in the study group who received the rehabilitation program had higher scores of SF-36 health domains than those in the control group who received routine hospital care.In addition, there was a statistical significant difference between the two groups in relation to overall quality of life.Conclusion: It can be concluded that mean scores of SF-36 health domains improved significantly in the study group compared to control group after applying the rehabilitation program.Recommendations: The rehabilitation program should be considered as an integral part in the hospital routine care of patients with LLA.

Aim At present, the traditional activated partial thromboplastin time (a-PTT) of 1.5–2.5 times the control value for monitoring unfractionated heparin (UFH) therapy continues to be used in the coagulation laboratory of Alexandria Main University Hospital. This study was conducted for the following reasons: to evaluate the relationship between heparin concentration and a-PTT results using Sysmex CA-1500; to define thea-PTT therapeutic range for our system; and to assess the level of agreement between a-PTT results and those obtained using the anti-Xa assay for monitoring UFH therapy. Results A significant positive correlation between a-PTT and anti-Xa assay results was noted (P=0.907, r=0.000, and P=0.098, r=0.000, for therapeutic a-PTT and therapeutic ratio, respectively). Regression analysis was carried out to determine the anti-Xa-derived therapeutic range (a-PTT results that correspond to a plasma heparin concentration of 0.3–0.7 U/ml by anti-Xa assay). The a-PTT therapeutic range was 64.4–107.93 s; the therapeutic range for the a-PTT ratio was 2.13–3.56 and that for the1.5–2.5 control method was 45.27–75.75 s. The agreement between the the a-PTT therapeutic range and the results of the anti-Xa assay was 78%, whereas the agreement between the 1.5–2.5 control method and the anti-Xa assay was 0.097%. Moreover, the potential for over therapeutic levels occurs more frequently with the 1.5–2.5 control method. Conclusion Anti-FXa-derived therapeutic range on Sysmex CA-1500 is superior to that obtained using the 1.5–2.5 control method in clinical decision making. Therapeutic ranges for various a-PTT reagent–coagulometer combinations could be provided by reagent manufacturers or central reference laboratories to the institutions that are not equipped to measure anti-Xa or to those for which the access to plasma samples from treated patients is limited.

Objective: To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia. Methods: Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed. Results: A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04). Conclusions: Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.

BACKGROUND:Inflammation is a key mechanism in human atherosclerotic plaque vulnerability and disruption. The objective was to determine the differential gene expression of pro- and anti-inflammatory factors in the fibrous cap and shoulder region of noncalcified and calcified carotid endarterectomy plaques.METHODS:Thirty carotid endarterectomy plaques were classified as type Va (noncalcified, n = 15) and type Vb (calcified, n = 15) in accordance with the American Heart Association consensus. Using laser capture microdissection, fibrous cap and shoulder regions were excised from frozen sections. Gene expression of pro- [interleukin 1 (IL-1), IL-8 and monocyte chemoattractant protein 1 (MCP-1)] and anti-inflammatory (IL-10) factors, and bone formation (bone morphogenetic protein 6 and osteocalcin) mediators were quantitated by real-time PCR. Protein levels were determined using Western blotting.RESULTS:Mean percent carotid stenosis and calcification area were 79 and 5% in Va-plaques (40% symptomatic) and 77 and 42% in Vb-plaques (20% symptomatic). Macrophages infiltrating the region of the fibrous cap and the shoulder were more numerous in non-calcified plaques compared with calcified plaques (p < 0.01]. mRNA expression of MCP-1 and IL-8, and protein levels of IL-8 were also greater in Va plaques compared to Vb plaques (p < 0.05). Protein levels and mRNA expression of osteocalcin were greater in Vb compared to Va plaques (p < 0.05).CONCLUSIONS:Fibrous cap inflammation is more likely to occur in noncalcified than in calcified plaques. These findings suggest that carotid atherosclerotic plaque calcification is a structural marker of plaque stability.

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Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.

Les anévrismes aortiques abdominaux sous-rénaux (AAA) avec un collet aortique sous-rénal hostile non accessible à au traitement endovasculaire (EVAR) relèvent d'une chirurgie directe avec clampage aortique sus-rénal. Nous avons comparé les résultats de la voie trans-péritonéale et de la voie rétropéritonéale pour la cure des AAA sous-rénaux nécessitant un clampage sus-rénal, et la fréquence relative de ces techniques après l'introduction d'EVAR dans notre pratique clinique. De janvier 1998 à septembre 2005, 478 anévrismes aortiques sous-rénaux ont été réparés de manière élective. Il y avait 160 (33%) chirurgies directes (71% trans-péritonéales et 29% rétropéritonéales) et 318 (67%) réparations endovasculaires. Dans 38 cas (24%) un clampage sus-rénal a été utilisé (47% des voies trans-péritonéales et 53% des voies rétropéritonéales) en raison d'un collet sous-rénal hostile. Un collet aortique hostile était défini comme un collet dont l'angulation était importante (>60°), un collet court (<15 mm), la présence de calcifications étendues, ou d'un thrombus circulaire. L'âge médian était de 70 ans ; 47% des patients étaient des hommes ; 16% avaient un diabète, 29% une insuffisance respiratoire, 53% une coronaropathie, et 11% une insuffisance rénale. La taille médiane des anévrismes était de 6,0 cm. Une analyse rétrospective a été faite pour comparer les résultats postopératoires à 30 jours entre les cohortes rétropéritonéale et trans-péritonéale. Les résultats étaient déterminés pendant deux périodes de temps pour évaluer si la chirurgie directe avec clampage sus-rénal était exécutée plus fréquemment en raison de la plus grande utilisation d'EVAR. Après 2002, le taux d'EVAR est passé de 60% à 71% (p = 0,04) tandis que la chirurgie directe diminuait de 40% à 29% (p = 0,01). La voie rétropéritonéale a doublé de 19% à 39%, alors que l'approche transpéritonéale diminuait de 81% à 61% (p = 0,02). Le clampage sus-rénal a augmenté de 11% après 2002. Il n'y avait aucune différence significative d'âge, de sexe, de taille des anévrismes, ou de comorbidités entre les groupes trans-péritonéal et rétropéritonéal avec clampage sus-rénal. La mortalité à 30 jours était de 2/38 (5%) et observée seulement dans le groupe trans-péritonéal. L'abord trans-péritonéal était associée à des pertes sanguines sensiblement plus importantes et à une plus grande durée de clampage sus-rénal (2.400 contre 1.800 mL et 38 contre 29,5 min ; p = 0,03), mais sans différence significative des complications postopératoires à 30 jours. Dans notre expérience de 7 ans, il y a eu une augmentation progressive de l'utilisation d'EVAR pour les AAA sous-rénaux. Parallèlement, plus d'AAA sous-rénaux avec un collet aortique hostile nécessitant un clampage aortique sus-rénal ont été traités. Dans de tels cas, l'abord rétropéritonéal est plus sûr, avec moins de pertes sanguines périopératoires et une durée de clampage sus-rénal plus courte. Ceci est probablement attribuable à une meilleure exposition de l'aorte abdominale sus-rénale, permettant une anastomose proximale plus sure.

OBJECTIVES:We investigated the utility of color duplex ultrasound (CDU)-derived common femoral artery (CFA) hemodynamics for detecting significant aortoiliac occlusive disease and predicting its severity. METHODS:From January 1997 to June 2001, 132 consecutive patients with lower extremity arterial insufficiency underwent both femoropopliteal CDU scanning and aortography with runoff studies. CDU-derived CFA waveform contour (monophasic, biphasic, or triphasic), peak systolic velocity (PSV), and acceleration time were recorded for each patient. Severity of aortoiliac occlusive disease was classified by arteriography into three distinct groups: normal or minimal disease (<50%, group 1), significant focal or diffuse stenoses (>/=50%, group 2), or total occlusion (group 3). Using probability and receiver operating characteristic curve analysis, waveform contour and PSV were compared alone and in combination with the arteriographic groups to identify waveform contours and threshold PSV, which may accurately differentiate the three categories of aortoiliac occlusive disease. RESULTS:Of 214 limbs available for study, 112 composed group 1, 70 composed group 2, and 32 composed group 3. Concomitant femoropopliteal disease was present in 47% of limbs in group 1, 53% of limbs in group 2, and 34% of limbs in group III. An abnormal CFA waveform contour (monophasic or biphasic) differentiated group 1 from groups 2 and 3, with 95% sensitivity, 89% specificity, 89% positive predictive value (PPV), 95% negative predictive value (NPV), and 92% accuracy. Mean PSV and acceleration time for monophasic and biphasic waveforms were 39 cm/sec +/- 19, 178 msec +/- 36 vs 95 cm/sec +/- 67, 97 msec +/- 31 respectively (P <.05). In differentiating between groups 2 and 3, the specificity, PPV, and accuracy for CFA PSV of =45 cm/sec alone and for the PSV =45 cm/sec combined with a CFA monophasic waveform were 89%, 76%, 85% and 97%, 92%, 88%, respectively. Concomitant significant superior femoral artery and bilateral iliac disease did not influence these findings. CONCLUSION:CFA PSV 45 cm/s or less combined with a monophasic waveform is highly predictive of ipsilateral iliac occlusion. These results were independent of contralateral iliac and distal superior femoral artery disease. CFA color duplex US scanning may be considered an alternative technique to direct duplex scanning of the aortoiliac segment in patients being evaluated for inflow endoluminal or bypass procedures.