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Surgery_Schwartz_6402 | Surgery_Schwartz | cerebrovascular events (including transient ischemic attack) within last 2 monthsActive bleeding diathesisRecent (<10 days) gastrointestinal bleedingNeurosurgery (intracranial or spinal) within last 3 monthsIntracranial trauma within last 3 monthsIntracranial malignancy or metastasisRelative major contraindicationsCardiopulmonary resuscitation within last 10 daysMajor nonvascular surgery or trauma within last 10 daysUncontrolled hypertension (>180 mmHg systolic or >110 mmHg diastolic)Puncture of noncompressible vesselIntracranial tumorRecent eye surgeryMinor contraindicationsHepatic failure, particularly with coagulopathyBacterial endocarditisPregnancyDiabetic hemorrhagic retinopathythe adequacy of clot removal. The artery is then closed and the patient fully anticoagulated.When an embolus lodges in the popliteal artery, in most cases it can be extracted via a femoral incision using the tech-niques previously described. A femoral approach is preferred because the larger diameter of | Surgery_Schwartz. cerebrovascular events (including transient ischemic attack) within last 2 monthsActive bleeding diathesisRecent (<10 days) gastrointestinal bleedingNeurosurgery (intracranial or spinal) within last 3 monthsIntracranial trauma within last 3 monthsIntracranial malignancy or metastasisRelative major contraindicationsCardiopulmonary resuscitation within last 10 daysMajor nonvascular surgery or trauma within last 10 daysUncontrolled hypertension (>180 mmHg systolic or >110 mmHg diastolic)Puncture of noncompressible vesselIntracranial tumorRecent eye surgeryMinor contraindicationsHepatic failure, particularly with coagulopathyBacterial endocarditisPregnancyDiabetic hemorrhagic retinopathythe adequacy of clot removal. The artery is then closed and the patient fully anticoagulated.When an embolus lodges in the popliteal artery, in most cases it can be extracted via a femoral incision using the tech-niques previously described. A femoral approach is preferred because the larger diameter of |
Surgery_Schwartz_6403 | Surgery_Schwartz | lodges in the popliteal artery, in most cases it can be extracted via a femoral incision using the tech-niques previously described. A femoral approach is preferred because the larger diameter of the femoral artery results in decreased likelihood of arterial compromise when the arte-riotomy is closed. The disadvantage with using the femoral approach for embolectomy is the greater difficulty involved in directing the embolectomy catheter into each of the infrapopli-teal arteries. Use of fluoroscopic imaging and an over-the-wire thrombectomy catheter can overcome this problem. Alterna-tively, use of a separate incision to expose the popliteal bifurca-tion may be necessary to achieve a complete thrombectomy.A more complex situation arises when a patient has antecedent peripheral vascular disease and in situ thrombosis develops on top of preexisting atheroma because, frequently, embolectomy catheters will not pass through these occlusions. Similarly, when a bypass graft fails, it is | Surgery_Schwartz. lodges in the popliteal artery, in most cases it can be extracted via a femoral incision using the tech-niques previously described. A femoral approach is preferred because the larger diameter of the femoral artery results in decreased likelihood of arterial compromise when the arte-riotomy is closed. The disadvantage with using the femoral approach for embolectomy is the greater difficulty involved in directing the embolectomy catheter into each of the infrapopli-teal arteries. Use of fluoroscopic imaging and an over-the-wire thrombectomy catheter can overcome this problem. Alterna-tively, use of a separate incision to expose the popliteal bifurca-tion may be necessary to achieve a complete thrombectomy.A more complex situation arises when a patient has antecedent peripheral vascular disease and in situ thrombosis develops on top of preexisting atheroma because, frequently, embolectomy catheters will not pass through these occlusions. Similarly, when a bypass graft fails, it is |
Surgery_Schwartz_6404 | Surgery_Schwartz | disease and in situ thrombosis develops on top of preexisting atheroma because, frequently, embolectomy catheters will not pass through these occlusions. Similarly, when a bypass graft fails, it is usually due to progres-sion of atheroma proximal or distal to the graft anastomoses or to intrinsic stenoses that develop within a vein graft. In these scenarios, expeditious angiography is useful to determine the extent of the occlusion, to search for inflow and distal outflow vessels, and to decide whether thrombolysis or surgery will be the better intervention. Although the surgeon’s preference tends to dictate the approach selected, the decision is based on the presence or absence of good target vessels and availability of a suitable bypass conduit. If there are good distal vessels and the saphenous vein is suitable, surgical bypass is recommended because it is fast, durable, and reliable. In the absence of a good distal target and saphenous vein, or in a patient at high risk for | Surgery_Schwartz. disease and in situ thrombosis develops on top of preexisting atheroma because, frequently, embolectomy catheters will not pass through these occlusions. Similarly, when a bypass graft fails, it is usually due to progres-sion of atheroma proximal or distal to the graft anastomoses or to intrinsic stenoses that develop within a vein graft. In these scenarios, expeditious angiography is useful to determine the extent of the occlusion, to search for inflow and distal outflow vessels, and to decide whether thrombolysis or surgery will be the better intervention. Although the surgeon’s preference tends to dictate the approach selected, the decision is based on the presence or absence of good target vessels and availability of a suitable bypass conduit. If there are good distal vessels and the saphenous vein is suitable, surgical bypass is recommended because it is fast, durable, and reliable. In the absence of a good distal target and saphenous vein, or in a patient at high risk for |
Surgery_Schwartz_6405 | Surgery_Schwartz | the saphenous vein is suitable, surgical bypass is recommended because it is fast, durable, and reliable. In the absence of a good distal target and saphenous vein, or in a patient at high risk for surgery, lysis is recommended.Bypass Graft Thrombectomy. Bypass thrombectomy is more likely to succeed with prosthetic bypasses. Bypass graft revision or replacement is more appropriate for acute vein graft failures because they are less likely to respond to thrombolysis and require some type of revision, such as valve lysis, interposition, or extension. Thrombectomy of autogenous grafts is prone to failure unless an anatomic cause for failure such as a retained valve or unligated side branch is found and corrected. The per-formance of a fasciotomy to circumvent reperfusion injury/com-partment syndrome is an important consideration.Complications Related to Treatment for Acute Limb IschemiaAdverse events related to catheter-directed thrombolysis are primarily related to bleeding | Surgery_Schwartz. the saphenous vein is suitable, surgical bypass is recommended because it is fast, durable, and reliable. In the absence of a good distal target and saphenous vein, or in a patient at high risk for surgery, lysis is recommended.Bypass Graft Thrombectomy. Bypass thrombectomy is more likely to succeed with prosthetic bypasses. Bypass graft revision or replacement is more appropriate for acute vein graft failures because they are less likely to respond to thrombolysis and require some type of revision, such as valve lysis, interposition, or extension. Thrombectomy of autogenous grafts is prone to failure unless an anatomic cause for failure such as a retained valve or unligated side branch is found and corrected. The per-formance of a fasciotomy to circumvent reperfusion injury/com-partment syndrome is an important consideration.Complications Related to Treatment for Acute Limb IschemiaAdverse events related to catheter-directed thrombolysis are primarily related to bleeding |
Surgery_Schwartz_6406 | Surgery_Schwartz | syndrome is an important consideration.Complications Related to Treatment for Acute Limb IschemiaAdverse events related to catheter-directed thrombolysis are primarily related to bleeding complications. The overall risk of hemorrhagic stroke from a thrombolysis procedure has been reported to be 1% to 2.3%, with 50% of hemorrhagic compli-cations occurring during the thrombolytic procedure.146 Hema-toma at the vascular puncture site has been reported in 12% to 17% of cases. Gastrointestinal bleeding is reported in 5% to 10% of cases. Hematuria following thrombolysis is uncom-mon and should prompt a search for urinary tumors. Hemor-rhage requiring transfusion can occur in approximately 25% of patients undergoing thrombolysis. Lytic agents are absolutely contraindicated in patients with intracranial surgery, intracra-nial hemorrhage within the last 3 months, or any active bleed-ing. Most bleeding complications occur at the arterial puncture sites, but concealed retroperitoneal bleeding | Surgery_Schwartz. syndrome is an important consideration.Complications Related to Treatment for Acute Limb IschemiaAdverse events related to catheter-directed thrombolysis are primarily related to bleeding complications. The overall risk of hemorrhagic stroke from a thrombolysis procedure has been reported to be 1% to 2.3%, with 50% of hemorrhagic compli-cations occurring during the thrombolytic procedure.146 Hema-toma at the vascular puncture site has been reported in 12% to 17% of cases. Gastrointestinal bleeding is reported in 5% to 10% of cases. Hematuria following thrombolysis is uncom-mon and should prompt a search for urinary tumors. Hemor-rhage requiring transfusion can occur in approximately 25% of patients undergoing thrombolysis. Lytic agents are absolutely contraindicated in patients with intracranial surgery, intracra-nial hemorrhage within the last 3 months, or any active bleed-ing. Most bleeding complications occur at the arterial puncture sites, but concealed retroperitoneal bleeding |
Surgery_Schwartz_6407 | Surgery_Schwartz | surgery, intracra-nial hemorrhage within the last 3 months, or any active bleed-ing. Most bleeding complications occur at the arterial puncture sites, but concealed retroperitoneal bleeding is possible. The most feared complication that patients can sustain is intrace-rebral hemorrhage. Older patients may be more susceptible Brunicardi_Ch23_p0897-p0980.indd 95627/02/19 4:15 PM 957ARTERIAL DISEASECHAPTER 23to this complication, and thus many interventionalists are extremely reticent to use thrombolysis in patients older than 80 years of age.Patients who are treated for acute ischemia are susceptible to two major complications following revascularization: reper-fusion and compartment syndromes. Other procedure-related complications include arterial rethrombosis, recurrent emboli-zation, and arterial injuries secondary to the balloon catheter manipulations.Reperfusion of the ischemic limb is variable in its physi-ologic effects and directly relates to the severity and extent of the | Surgery_Schwartz. surgery, intracra-nial hemorrhage within the last 3 months, or any active bleed-ing. Most bleeding complications occur at the arterial puncture sites, but concealed retroperitoneal bleeding is possible. The most feared complication that patients can sustain is intrace-rebral hemorrhage. Older patients may be more susceptible Brunicardi_Ch23_p0897-p0980.indd 95627/02/19 4:15 PM 957ARTERIAL DISEASECHAPTER 23to this complication, and thus many interventionalists are extremely reticent to use thrombolysis in patients older than 80 years of age.Patients who are treated for acute ischemia are susceptible to two major complications following revascularization: reper-fusion and compartment syndromes. Other procedure-related complications include arterial rethrombosis, recurrent emboli-zation, and arterial injuries secondary to the balloon catheter manipulations.Reperfusion of the ischemic limb is variable in its physi-ologic effects and directly relates to the severity and extent of the |
Surgery_Schwartz_6408 | Surgery_Schwartz | and arterial injuries secondary to the balloon catheter manipulations.Reperfusion of the ischemic limb is variable in its physi-ologic effects and directly relates to the severity and extent of the ischemia. Patients with a saddle embolus of the aortic bifurcation and severely ischemic limbs may develop the full-blown “reperfusion syndrome,” whereas patients with minimal muscle ischemia who are reperfused in a timely fashion essen-tially develop no effects. Many patients with ALI have severe underlying cardiac disease and are unable to tolerate even short ischemic periods. Complications occurring after revasculariza-tion of the lower extremity and causes of recurrent thrombosis are listed in Table 23-22.Compartment syndrome occurs after prolonged ischemia is followed by reperfusion. The capillaries leak fluid into the interstitial space in the muscles, which are enclosed within a nondistensible fascial envelope. When the pressure inside the compartment exceeds the capillary perfusion | Surgery_Schwartz. and arterial injuries secondary to the balloon catheter manipulations.Reperfusion of the ischemic limb is variable in its physi-ologic effects and directly relates to the severity and extent of the ischemia. Patients with a saddle embolus of the aortic bifurcation and severely ischemic limbs may develop the full-blown “reperfusion syndrome,” whereas patients with minimal muscle ischemia who are reperfused in a timely fashion essen-tially develop no effects. Many patients with ALI have severe underlying cardiac disease and are unable to tolerate even short ischemic periods. Complications occurring after revasculariza-tion of the lower extremity and causes of recurrent thrombosis are listed in Table 23-22.Compartment syndrome occurs after prolonged ischemia is followed by reperfusion. The capillaries leak fluid into the interstitial space in the muscles, which are enclosed within a nondistensible fascial envelope. When the pressure inside the compartment exceeds the capillary perfusion |
Surgery_Schwartz_6409 | Surgery_Schwartz | leak fluid into the interstitial space in the muscles, which are enclosed within a nondistensible fascial envelope. When the pressure inside the compartment exceeds the capillary perfusion pressure, nutrient flow ceases and progressive ischemia occurs, even in the pres-ence of peripheral pulses. Consequently, every patient who has sustained an ischemic event and is reperfused is monitored for compartment syndrome, which is characterized by excessive Table 23-22Complications of arterial revascularizationCompartment syndromeIschemic neuropathyMuscle necrosisRecurrent thrombosisLower leg swellingReperfusion syndrome Hypotension Hyperkalemia Myoglobinuria Renal failureTable 23-23Fascial compartments of the lower leg ANTERIOR COMPARTMENTLATERAL COMPARTMENTSUPERFICIAL POSTERIOR COMPARTMENTDEEP POSTERIOR COMPARTMENTMusclesTibialis anteriorExtensor digitorum longusPeroneus tertiusExtensor hallucis longusExtensor digitorum brevisExtensor hallucis brevisPeroneus longusPeroneus | Surgery_Schwartz. leak fluid into the interstitial space in the muscles, which are enclosed within a nondistensible fascial envelope. When the pressure inside the compartment exceeds the capillary perfusion pressure, nutrient flow ceases and progressive ischemia occurs, even in the pres-ence of peripheral pulses. Consequently, every patient who has sustained an ischemic event and is reperfused is monitored for compartment syndrome, which is characterized by excessive Table 23-22Complications of arterial revascularizationCompartment syndromeIschemic neuropathyMuscle necrosisRecurrent thrombosisLower leg swellingReperfusion syndrome Hypotension Hyperkalemia Myoglobinuria Renal failureTable 23-23Fascial compartments of the lower leg ANTERIOR COMPARTMENTLATERAL COMPARTMENTSUPERFICIAL POSTERIOR COMPARTMENTDEEP POSTERIOR COMPARTMENTMusclesTibialis anteriorExtensor digitorum longusPeroneus tertiusExtensor hallucis longusExtensor digitorum brevisExtensor hallucis brevisPeroneus longusPeroneus |
Surgery_Schwartz_6410 | Surgery_Schwartz | COMPARTMENTDEEP POSTERIOR COMPARTMENTMusclesTibialis anteriorExtensor digitorum longusPeroneus tertiusExtensor hallucis longusExtensor digitorum brevisExtensor hallucis brevisPeroneus longusPeroneus brevisGastrocnemiusPlantarisSoleusTibialis posteriorFlexor digitorum longusFlexor hallucis longusArteryAnterior tibial arteryAnterior and posterior tibial branches of the popliteal arteryPosterior tibial arteryPeroneal arteryNerveDeep peroneal nerveSuperficial peroneal nerve Tibial nervepain in the compartment, pain on passive stretching of the com-partment, and sensory loss due to nerve compression of the nerves coursing through the compartment (Table 23-23 and Fig. 23-62). The most commonly affected compartment is the anterior compartment in the leg. Numbness in the web space between the first and second toes is diagnostic due to com-pression of the deep peroneal nerve. Compartment pressure is measured by inserting an arterial line into the compartment and recording the pressure. | Surgery_Schwartz. COMPARTMENTDEEP POSTERIOR COMPARTMENTMusclesTibialis anteriorExtensor digitorum longusPeroneus tertiusExtensor hallucis longusExtensor digitorum brevisExtensor hallucis brevisPeroneus longusPeroneus brevisGastrocnemiusPlantarisSoleusTibialis posteriorFlexor digitorum longusFlexor hallucis longusArteryAnterior tibial arteryAnterior and posterior tibial branches of the popliteal arteryPosterior tibial arteryPeroneal arteryNerveDeep peroneal nerveSuperficial peroneal nerve Tibial nervepain in the compartment, pain on passive stretching of the com-partment, and sensory loss due to nerve compression of the nerves coursing through the compartment (Table 23-23 and Fig. 23-62). The most commonly affected compartment is the anterior compartment in the leg. Numbness in the web space between the first and second toes is diagnostic due to com-pression of the deep peroneal nerve. Compartment pressure is measured by inserting an arterial line into the compartment and recording the pressure. |
Surgery_Schwartz_6411 | Surgery_Schwartz | the first and second toes is diagnostic due to com-pression of the deep peroneal nerve. Compartment pressure is measured by inserting an arterial line into the compartment and recording the pressure. Although controversial, pressures greater than 20 mmHg are an indication for fasciotomy. Com-partment pressures are relieved in the leg by medial and lateral incisions. Through the medial incision, long openings are then made in the fascia of the superficial and deep posterior com-partments. Through the lateral incision, the anterior and pero-neal compartments are opened. Both skin and fascial incisions should be of adequate length to ensure full compartment decom-pression. Laboratory evidence of rhabdomyolysis is seen in 20% of cases. The myoglobin from damaged muscle precipitates in kidney tubules and causes acute tubular necrosis. Alkalinization of urine increases the solubility of myoglobin, thus preventing Tibia AnteriorcompartmentLateralcompartmentFibulaDeep | Surgery_Schwartz. the first and second toes is diagnostic due to com-pression of the deep peroneal nerve. Compartment pressure is measured by inserting an arterial line into the compartment and recording the pressure. Although controversial, pressures greater than 20 mmHg are an indication for fasciotomy. Com-partment pressures are relieved in the leg by medial and lateral incisions. Through the medial incision, long openings are then made in the fascia of the superficial and deep posterior com-partments. Through the lateral incision, the anterior and pero-neal compartments are opened. Both skin and fascial incisions should be of adequate length to ensure full compartment decom-pression. Laboratory evidence of rhabdomyolysis is seen in 20% of cases. The myoglobin from damaged muscle precipitates in kidney tubules and causes acute tubular necrosis. Alkalinization of urine increases the solubility of myoglobin, thus preventing Tibia AnteriorcompartmentLateralcompartmentFibulaDeep |
Surgery_Schwartz_6412 | Surgery_Schwartz | in kidney tubules and causes acute tubular necrosis. Alkalinization of urine increases the solubility of myoglobin, thus preventing Tibia AnteriorcompartmentLateralcompartmentFibulaDeep posteriorcompartmentSuperficial posterior compartmentFigure 23-62. Schematic illustration of fascial compartments of the lower extremity.Brunicardi_Ch23_p0897-p0980.indd 95727/02/19 4:15 PM 958SPECIFIC CONSIDERATIONSPART IIit from crystallizing in the tubules. In addition to alkalinization, therapy consists of forced saline diuresis and removal of the source of dead muscle that is releasing the myoglobin.Clinical Manifestations of Chronic Limb IschemiaThe term CLI is reserved for patients with objectively proven arterial occlusive disease and symptoms lasting for more than 2 weeks. Symptoms include rest pain and tissue loss, such as ulceration or gangrene (Table 23-24). The diagnosis should be corroborated with noninvasive diagnostic tests, such as the ABI, toe pressures, and transcutaneous | Surgery_Schwartz. in kidney tubules and causes acute tubular necrosis. Alkalinization of urine increases the solubility of myoglobin, thus preventing Tibia AnteriorcompartmentLateralcompartmentFibulaDeep posteriorcompartmentSuperficial posterior compartmentFigure 23-62. Schematic illustration of fascial compartments of the lower extremity.Brunicardi_Ch23_p0897-p0980.indd 95727/02/19 4:15 PM 958SPECIFIC CONSIDERATIONSPART IIit from crystallizing in the tubules. In addition to alkalinization, therapy consists of forced saline diuresis and removal of the source of dead muscle that is releasing the myoglobin.Clinical Manifestations of Chronic Limb IschemiaThe term CLI is reserved for patients with objectively proven arterial occlusive disease and symptoms lasting for more than 2 weeks. Symptoms include rest pain and tissue loss, such as ulceration or gangrene (Table 23-24). The diagnosis should be corroborated with noninvasive diagnostic tests, such as the ABI, toe pressures, and transcutaneous |
Surgery_Schwartz_6413 | Surgery_Schwartz | rest pain and tissue loss, such as ulceration or gangrene (Table 23-24). The diagnosis should be corroborated with noninvasive diagnostic tests, such as the ABI, toe pressures, and transcutaneous oxygen measurements. Ischemic rest pain most commonly occurs below an ankle pres-sure of 50 mmHg or a toe pressure less than 30 mmHg. Ulcers are not always of an ischemic etiology (Table 23-25). In many instances, there are other etiologic factors (traumatic, venous, or neuropathic) that are contributory, but it is underlying peripheral arterial disease that may be responsible for delayed or absent healing (Fig. 23-63). Healing of ulcers requires an inflammatory response and greater perfusion than is required to support intact skin and underlying tissues. As a result, the ankle and toe pres-sure levels needed for healing are higher than the pressures seen with ischemic rest pain. For patients with ulcers or gangrene, the presence of CLI is suggested by an ankle pressure less than 70 mmHg or a | Surgery_Schwartz. rest pain and tissue loss, such as ulceration or gangrene (Table 23-24). The diagnosis should be corroborated with noninvasive diagnostic tests, such as the ABI, toe pressures, and transcutaneous oxygen measurements. Ischemic rest pain most commonly occurs below an ankle pres-sure of 50 mmHg or a toe pressure less than 30 mmHg. Ulcers are not always of an ischemic etiology (Table 23-25). In many instances, there are other etiologic factors (traumatic, venous, or neuropathic) that are contributory, but it is underlying peripheral arterial disease that may be responsible for delayed or absent healing (Fig. 23-63). Healing of ulcers requires an inflammatory response and greater perfusion than is required to support intact skin and underlying tissues. As a result, the ankle and toe pres-sure levels needed for healing are higher than the pressures seen with ischemic rest pain. For patients with ulcers or gangrene, the presence of CLI is suggested by an ankle pressure less than 70 mmHg or a |
Surgery_Schwartz_6414 | Surgery_Schwartz | needed for healing are higher than the pressures seen with ischemic rest pain. For patients with ulcers or gangrene, the presence of CLI is suggested by an ankle pressure less than 70 mmHg or a toe systolic pressure less than 50 mmHg.147 It is important to understand that there is no definite consensus regarding the vascular hemodynamic parameters required to make the diagnosis of CLI.One of the most common sites for occlusive disease is in the distal SFA as it passes deep through the adductor canal. It may be that the entrapment by the adductor hiatus prevents the compensatory dilation that occurs in atherosclerotic vessels. Stenoses, which develop here, progress to occlusion of the dis-tal third of the SFA (Fig. 23-64). When distal SFA occlusion develops slowly, it may be totally asymptomatic because of development of collaterals from the proximal SFA, or the PFA can bypass the occlusion and reconstitute the popliteal artery. Table 23-24Clinical categories of chronic limb | Surgery_Schwartz. needed for healing are higher than the pressures seen with ischemic rest pain. For patients with ulcers or gangrene, the presence of CLI is suggested by an ankle pressure less than 70 mmHg or a toe systolic pressure less than 50 mmHg.147 It is important to understand that there is no definite consensus regarding the vascular hemodynamic parameters required to make the diagnosis of CLI.One of the most common sites for occlusive disease is in the distal SFA as it passes deep through the adductor canal. It may be that the entrapment by the adductor hiatus prevents the compensatory dilation that occurs in atherosclerotic vessels. Stenoses, which develop here, progress to occlusion of the dis-tal third of the SFA (Fig. 23-64). When distal SFA occlusion develops slowly, it may be totally asymptomatic because of development of collaterals from the proximal SFA, or the PFA can bypass the occlusion and reconstitute the popliteal artery. Table 23-24Clinical categories of chronic limb |
Surgery_Schwartz_6415 | Surgery_Schwartz | asymptomatic because of development of collaterals from the proximal SFA, or the PFA can bypass the occlusion and reconstitute the popliteal artery. Table 23-24Clinical categories of chronic limb ischemiaGRADECATEGORYCLINICAL DESCRIPTIONOBJECTIVE CRITERIA00Asymptomatic—no hemodynamically significant occlusive diseaseNormal treadmill or reactive hyperemia test 1Mild claudicationAble to complete treadmill exercisea; AP after exercise >50 mmHg but at least 20 mmHg lower than resting valueI2Moderate claudicationBetween categories 1 and 3 3Severe claudicationCannot complete standard treadmill exercisea and AP after exercise <50 mmHgIIb4Ischemic rest painResting AP <40 mmHg, flat or barely pulsatile ankle or metatarsal PVR; TP <30 mmHgIIIb5Minor tissue loss—nonhealing ulcer, focal gangrene with diffuse pedal ischemiaResting AP <60 mmHg, ankle or metatarsal PVR flat or barely pulsatile; TP <40 mmHg 6Major tissue loss—extending above TM level, functional foot no longer salvageableSame as | Surgery_Schwartz. asymptomatic because of development of collaterals from the proximal SFA, or the PFA can bypass the occlusion and reconstitute the popliteal artery. Table 23-24Clinical categories of chronic limb ischemiaGRADECATEGORYCLINICAL DESCRIPTIONOBJECTIVE CRITERIA00Asymptomatic—no hemodynamically significant occlusive diseaseNormal treadmill or reactive hyperemia test 1Mild claudicationAble to complete treadmill exercisea; AP after exercise >50 mmHg but at least 20 mmHg lower than resting valueI2Moderate claudicationBetween categories 1 and 3 3Severe claudicationCannot complete standard treadmill exercisea and AP after exercise <50 mmHgIIb4Ischemic rest painResting AP <40 mmHg, flat or barely pulsatile ankle or metatarsal PVR; TP <30 mmHgIIIb5Minor tissue loss—nonhealing ulcer, focal gangrene with diffuse pedal ischemiaResting AP <60 mmHg, ankle or metatarsal PVR flat or barely pulsatile; TP <40 mmHg 6Major tissue loss—extending above TM level, functional foot no longer salvageableSame as |
Surgery_Schwartz_6416 | Surgery_Schwartz | with diffuse pedal ischemiaResting AP <60 mmHg, ankle or metatarsal PVR flat or barely pulsatile; TP <40 mmHg 6Major tissue loss—extending above TM level, functional foot no longer salvageableSame as category 5aFive minutes at 2 miles per hour on a 12% incline of treadmill exercise.bGrades II and III, categories 4, 5, and 6, are encompassed by the term chronic critical ischemia.AP = ankle pressure; PVR = pulse volume recording; TM = transmetatarsal; TP = toe pressure.Table 23-25Symptoms and signs of neuropathic ulcer versus ischemic ulcerNEUROPATHIC ULCERISCHEMIC ULCERPainlessPainfulNormal pulsesAbsent pulsesRegular margins, typically punched-out appearanceIrregular marginOften located on plantar surface of footCommonly located on toes, glabrous marginsPresence of callusesCalluses absent or infrequentLoss of sensation, reflexes, and vibrationVariable sensory findingsIncreased in blood flow (arteriovenous shunting)Decreased in blood flowDilated veinsCollapsed veinsDry, warm footCold | Surgery_Schwartz. with diffuse pedal ischemiaResting AP <60 mmHg, ankle or metatarsal PVR flat or barely pulsatile; TP <40 mmHg 6Major tissue loss—extending above TM level, functional foot no longer salvageableSame as category 5aFive minutes at 2 miles per hour on a 12% incline of treadmill exercise.bGrades II and III, categories 4, 5, and 6, are encompassed by the term chronic critical ischemia.AP = ankle pressure; PVR = pulse volume recording; TM = transmetatarsal; TP = toe pressure.Table 23-25Symptoms and signs of neuropathic ulcer versus ischemic ulcerNEUROPATHIC ULCERISCHEMIC ULCERPainlessPainfulNormal pulsesAbsent pulsesRegular margins, typically punched-out appearanceIrregular marginOften located on plantar surface of footCommonly located on toes, glabrous marginsPresence of callusesCalluses absent or infrequentLoss of sensation, reflexes, and vibrationVariable sensory findingsIncreased in blood flow (arteriovenous shunting)Decreased in blood flowDilated veinsCollapsed veinsDry, warm footCold |
Surgery_Schwartz_6417 | Surgery_Schwartz | or infrequentLoss of sensation, reflexes, and vibrationVariable sensory findingsIncreased in blood flow (arteriovenous shunting)Decreased in blood flowDilated veinsCollapsed veinsDry, warm footCold footBony deformitiesNo bony deformitiesRed or hyperemic in appearancePale and cyanotic in appearanceSymptom development is a function of the extent of occlusion, adequacy of collaterals, and the activity level of the patients.Presenting symptoms of femoropopliteal occlusive dis-ease are broadly classified into two types: limb-threatening and non–limb-threatening ischemia. Claudication is non– limb-threatening, while rest pain, ulceration, and gangrene are limb-threatening and warrant urgent intervention. Occlusive disease of the femoral artery may be isolated or occur in con-junction with multilevel disease that involves both the aortoil-iac segment and the tibial vessels. Symptoms in patients with Brunicardi_Ch23_p0897-p0980.indd 95827/02/19 4:15 PM 959ARTERIAL DISEASECHAPTER | Surgery_Schwartz. or infrequentLoss of sensation, reflexes, and vibrationVariable sensory findingsIncreased in blood flow (arteriovenous shunting)Decreased in blood flowDilated veinsCollapsed veinsDry, warm footCold footBony deformitiesNo bony deformitiesRed or hyperemic in appearancePale and cyanotic in appearanceSymptom development is a function of the extent of occlusion, adequacy of collaterals, and the activity level of the patients.Presenting symptoms of femoropopliteal occlusive dis-ease are broadly classified into two types: limb-threatening and non–limb-threatening ischemia. Claudication is non– limb-threatening, while rest pain, ulceration, and gangrene are limb-threatening and warrant urgent intervention. Occlusive disease of the femoral artery may be isolated or occur in con-junction with multilevel disease that involves both the aortoil-iac segment and the tibial vessels. Symptoms in patients with Brunicardi_Ch23_p0897-p0980.indd 95827/02/19 4:15 PM 959ARTERIAL DISEASECHAPTER |
Surgery_Schwartz_6418 | Surgery_Schwartz | multilevel disease that involves both the aortoil-iac segment and the tibial vessels. Symptoms in patients with Brunicardi_Ch23_p0897-p0980.indd 95827/02/19 4:15 PM 959ARTERIAL DISEASECHAPTER 23BAFigure 23-63. A. A neuropathic ulcer is characterized by a punched-out appearance with loss of sensation in the surrounding skin. The foot may be warm to touch, and pulses may be present in the distal pedal arteries. B. An ischemic ulcer is characterized by a gangrenous skin change in the foot or toes. The foot is usually cold to touch with absent pedal pulses. The foot is painful to touch with decreased distal capil-lary refills.Figure 23-64. Computed tomography angiogram of a patient with an occluded left superficial femoral artery (single long arrow) with reconstituted superficial femoral artery at the level of mid-thigh. Diffuse arterial calcifications (double small arrows) are noted in the mid and distal left superficial femoral arteries.multilevel disease are more severe than in | Surgery_Schwartz. multilevel disease that involves both the aortoil-iac segment and the tibial vessels. Symptoms in patients with Brunicardi_Ch23_p0897-p0980.indd 95827/02/19 4:15 PM 959ARTERIAL DISEASECHAPTER 23BAFigure 23-63. A. A neuropathic ulcer is characterized by a punched-out appearance with loss of sensation in the surrounding skin. The foot may be warm to touch, and pulses may be present in the distal pedal arteries. B. An ischemic ulcer is characterized by a gangrenous skin change in the foot or toes. The foot is usually cold to touch with absent pedal pulses. The foot is painful to touch with decreased distal capil-lary refills.Figure 23-64. Computed tomography angiogram of a patient with an occluded left superficial femoral artery (single long arrow) with reconstituted superficial femoral artery at the level of mid-thigh. Diffuse arterial calcifications (double small arrows) are noted in the mid and distal left superficial femoral arteries.multilevel disease are more severe than in |
Surgery_Schwartz_6419 | Surgery_Schwartz | artery at the level of mid-thigh. Diffuse arterial calcifications (double small arrows) are noted in the mid and distal left superficial femoral arteries.multilevel disease are more severe than in those with single-level disease. Pain from isolated SFA and popliteal occlusion typically manifests as calf claudication. Cramping pain develops in the calf on ambulation, occurs at a reproducible distance, and is relieved by rest. Activities such as climbing stairs or going uphill also exacerbate the pain. Many patients report worsen-ing symptoms during cold weather. It is important to evaluate whether the symptoms are progressive or static. In greater than 70% of patients, the disease is stable, particularly with risk fac-tor modification.Progression of the underlying atherosclerotic process is more likely to occur in patients with diabetes, those who con-tinue to smoke, and those who fail to modify their atherosclerotic risk factors. In comparison, rest pain is constant, and usually | Surgery_Schwartz. artery at the level of mid-thigh. Diffuse arterial calcifications (double small arrows) are noted in the mid and distal left superficial femoral arteries.multilevel disease are more severe than in those with single-level disease. Pain from isolated SFA and popliteal occlusion typically manifests as calf claudication. Cramping pain develops in the calf on ambulation, occurs at a reproducible distance, and is relieved by rest. Activities such as climbing stairs or going uphill also exacerbate the pain. Many patients report worsen-ing symptoms during cold weather. It is important to evaluate whether the symptoms are progressive or static. In greater than 70% of patients, the disease is stable, particularly with risk fac-tor modification.Progression of the underlying atherosclerotic process is more likely to occur in patients with diabetes, those who con-tinue to smoke, and those who fail to modify their atherosclerotic risk factors. In comparison, rest pain is constant, and usually |
Surgery_Schwartz_6420 | Surgery_Schwartz | is more likely to occur in patients with diabetes, those who con-tinue to smoke, and those who fail to modify their atherosclerotic risk factors. In comparison, rest pain is constant, and usually occurs in the forefoot across the metatarsophalangeal joint. It is worse at night and requires placing the foot in a dependent posi-tion to improve symptoms. Patients may report that they either sleep in a chair or hang the foot off the side of the bed. The pain is severe and relentless, even with narcotics. Ischemic ulcer-ation most commonly involves the toes. Any toe can be affected. Occasionally ulcers develop on the dorsum of the foot. Ulcer-ation can occur in atypical positions in an ischemic foot from trauma such as friction from poorly fitting shoes. Injury to a foot with borderline ischemia can convert an otherwise stable situ-ation into one that is limb-threatening. The initial development of gangrene commonly involves the digits. As with all vascular patients, it is important to | Surgery_Schwartz. is more likely to occur in patients with diabetes, those who con-tinue to smoke, and those who fail to modify their atherosclerotic risk factors. In comparison, rest pain is constant, and usually occurs in the forefoot across the metatarsophalangeal joint. It is worse at night and requires placing the foot in a dependent posi-tion to improve symptoms. Patients may report that they either sleep in a chair or hang the foot off the side of the bed. The pain is severe and relentless, even with narcotics. Ischemic ulcer-ation most commonly involves the toes. Any toe can be affected. Occasionally ulcers develop on the dorsum of the foot. Ulcer-ation can occur in atypical positions in an ischemic foot from trauma such as friction from poorly fitting shoes. Injury to a foot with borderline ischemia can convert an otherwise stable situ-ation into one that is limb-threatening. The initial development of gangrene commonly involves the digits. As with all vascular patients, it is important to |
Surgery_Schwartz_6421 | Surgery_Schwartz | can convert an otherwise stable situ-ation into one that is limb-threatening. The initial development of gangrene commonly involves the digits. As with all vascular patients, it is important to evaluate their risk factors, intercurrent cardiac diseases, and any prior vascular interventions.Treatment Considerations for Chronic Limb IschemiaPatients with vascular diseases frequently have complicated medical comorbidities. Careful patient evaluation and selection should be performed for any peripheral arterial vascular proce-dure. The fundamental principle is to assess not only the surgi-cal risk from the peripheral arterial system but also the global nature of the atherosclerotic process. Full cardiac evaluations are often necessary due to the high incidence of concomitant atherosclerotic coronary artery disease, resulting in a high risk for ischemic events. Hertzer and associates reviewed coronary angiographies on 1000 patients undergoing elective vascu-lar procedure and identified | Surgery_Schwartz. can convert an otherwise stable situ-ation into one that is limb-threatening. The initial development of gangrene commonly involves the digits. As with all vascular patients, it is important to evaluate their risk factors, intercurrent cardiac diseases, and any prior vascular interventions.Treatment Considerations for Chronic Limb IschemiaPatients with vascular diseases frequently have complicated medical comorbidities. Careful patient evaluation and selection should be performed for any peripheral arterial vascular proce-dure. The fundamental principle is to assess not only the surgi-cal risk from the peripheral arterial system but also the global nature of the atherosclerotic process. Full cardiac evaluations are often necessary due to the high incidence of concomitant atherosclerotic coronary artery disease, resulting in a high risk for ischemic events. Hertzer and associates reviewed coronary angiographies on 1000 patients undergoing elective vascu-lar procedure and identified |
Surgery_Schwartz_6422 | Surgery_Schwartz | coronary artery disease, resulting in a high risk for ischemic events. Hertzer and associates reviewed coronary angiographies on 1000 patients undergoing elective vascu-lar procedure and identified 25% of concomitant correctable coronary artery disease, including 21% in patients undergoing elective peripheral vascular intervention.5 Conte and associates analyzed their 20-year experience in 1642 open lower extremity reconstructive surgeries and concluded that patients requiring lower extremity reconstruction presented an increasingly com-plex medical and surgical challenge compared with the previous decade in a tertiary practice setting.148 With aging of the popu-lation, a growing number of vascular patients have prohibitive medical comorbidities and are deemed high-risk for open sur-gical repair. Endovascular intervention provides an attractive alternative.As for open surgical repair, the clinical indications for endovascular intervention of lower extremity peripheral arte-rial | Surgery_Schwartz. coronary artery disease, resulting in a high risk for ischemic events. Hertzer and associates reviewed coronary angiographies on 1000 patients undergoing elective vascu-lar procedure and identified 25% of concomitant correctable coronary artery disease, including 21% in patients undergoing elective peripheral vascular intervention.5 Conte and associates analyzed their 20-year experience in 1642 open lower extremity reconstructive surgeries and concluded that patients requiring lower extremity reconstruction presented an increasingly com-plex medical and surgical challenge compared with the previous decade in a tertiary practice setting.148 With aging of the popu-lation, a growing number of vascular patients have prohibitive medical comorbidities and are deemed high-risk for open sur-gical repair. Endovascular intervention provides an attractive alternative.As for open surgical repair, the clinical indications for endovascular intervention of lower extremity peripheral arte-rial |
Surgery_Schwartz_6423 | Surgery_Schwartz | repair. Endovascular intervention provides an attractive alternative.As for open surgical repair, the clinical indications for endovascular intervention of lower extremity peripheral arte-rial diseases include lifestyle-limiting claudication, ischemic rest pain, and tissue loss or gangrene. Importantly, endovas-cular procedures should be performed by a competent vas-cular interventionist who understands the vascular disease process and is familiar with a variety of endovascular tech-niques. In addition, certain lesions may not be amendable Brunicardi_Ch23_p0897-p0980.indd 95927/02/19 4:15 PM 960SPECIFIC CONSIDERATIONSPART IIto endovascular treatment or may be associated with poor outcomes, such as long segment occlusion, heavily calcified lesion, orifice lesion, or lesions that cannot be traversed by a guidewire. Proper selection of patients and techniques is criti-cal in achieving good long-term outcome.Endovascular intervention for lower extremity occlusive disease is | Surgery_Schwartz. repair. Endovascular intervention provides an attractive alternative.As for open surgical repair, the clinical indications for endovascular intervention of lower extremity peripheral arte-rial diseases include lifestyle-limiting claudication, ischemic rest pain, and tissue loss or gangrene. Importantly, endovas-cular procedures should be performed by a competent vas-cular interventionist who understands the vascular disease process and is familiar with a variety of endovascular tech-niques. In addition, certain lesions may not be amendable Brunicardi_Ch23_p0897-p0980.indd 95927/02/19 4:15 PM 960SPECIFIC CONSIDERATIONSPART IIto endovascular treatment or may be associated with poor outcomes, such as long segment occlusion, heavily calcified lesion, orifice lesion, or lesions that cannot be traversed by a guidewire. Proper selection of patients and techniques is criti-cal in achieving good long-term outcome.Endovascular intervention for lower extremity occlusive disease is |
Surgery_Schwartz_6424 | Surgery_Schwartz | cannot be traversed by a guidewire. Proper selection of patients and techniques is criti-cal in achieving good long-term outcome.Endovascular intervention for lower extremity occlusive disease is continuously evolving. Success and patency rates of endovascular intervention are closely related to the anatomic and morphologic characteristics of the treated lesions. The TASC work group made recommendations on the intervention strate-gies of lower extremity arterial diseases based on the morpho-logic characteristics. Based on TASC guidelines, endovascular treatment is recommended for type A lesions, open surgery is recommended for type D lesions, and no recommendations were made for types B and C lesions. However, with rapid advance-ment in endovascular technologies, there are increased numbers of lesions amendable to endovascular interventions.There is less literature support for infrapopliteal endo-vascular intervention due to higher complication and lower success rates. The treatment | Surgery_Schwartz. cannot be traversed by a guidewire. Proper selection of patients and techniques is criti-cal in achieving good long-term outcome.Endovascular intervention for lower extremity occlusive disease is continuously evolving. Success and patency rates of endovascular intervention are closely related to the anatomic and morphologic characteristics of the treated lesions. The TASC work group made recommendations on the intervention strate-gies of lower extremity arterial diseases based on the morpho-logic characteristics. Based on TASC guidelines, endovascular treatment is recommended for type A lesions, open surgery is recommended for type D lesions, and no recommendations were made for types B and C lesions. However, with rapid advance-ment in endovascular technologies, there are increased numbers of lesions amendable to endovascular interventions.There is less literature support for infrapopliteal endo-vascular intervention due to higher complication and lower success rates. The treatment |
Surgery_Schwartz_6425 | Surgery_Schwartz | of lesions amendable to endovascular interventions.There is less literature support for infrapopliteal endo-vascular intervention due to higher complication and lower success rates. The treatment is restricted for patients with limb-threatening ischemia who lack surgical alternatives. However, with further advancement of endovascular technology and the development of new devices, endovascular intervention is becoming an integral part of treatment (Table 23-26). By itself or combined with open technique, percutaneous intervention plays an important role in therapeutic options for lower extrem-ity occlusive disease. As described by TASC guidelines, four criteria should be measured to evaluate the clinical success of the treatment: improvement in walking distance, symptomatic improvement, quality of life, and overall graft patency. These criteria should all be carefully weighed and evaluated for each individual prior to endovascular therapy.Table 23-26Summary of endovascular treatment | Surgery_Schwartz. of lesions amendable to endovascular interventions.There is less literature support for infrapopliteal endo-vascular intervention due to higher complication and lower success rates. The treatment is restricted for patients with limb-threatening ischemia who lack surgical alternatives. However, with further advancement of endovascular technology and the development of new devices, endovascular intervention is becoming an integral part of treatment (Table 23-26). By itself or combined with open technique, percutaneous intervention plays an important role in therapeutic options for lower extrem-ity occlusive disease. As described by TASC guidelines, four criteria should be measured to evaluate the clinical success of the treatment: improvement in walking distance, symptomatic improvement, quality of life, and overall graft patency. These criteria should all be carefully weighed and evaluated for each individual prior to endovascular therapy.Table 23-26Summary of endovascular treatment |
Surgery_Schwartz_6426 | Surgery_Schwartz | quality of life, and overall graft patency. These criteria should all be carefully weighed and evaluated for each individual prior to endovascular therapy.Table 23-26Summary of endovascular treatment strategies using device-based infrapopliteal interventionINTERVENTIONADVANTAGESDISADVANTAGESAngioplasty• Easy to use• Broad range of applications• Failure in long lesions, calcified lesions, and disease at multiple levelsBalloon-expandable stent• Overcomes arterial recoil from angioplasty• Useful in treatment of flow-limiting dissection• Crushability can lead to restenosis• Poor distal runoff can result in stent thrombosis• Limited dataSelf-expanding stent• Vessel conformability and wall apposition prevent kinking and crushing of stent• Limited sizes• Limited data; multicenter trials under wayBioabsorbable stent• Overcomes arterial recoil from angioplasty• Absorbed long term to prevent risk of stent thrombosis• Limited data; multicenter trials under wayCryoplasty• Reduces the risk of | Surgery_Schwartz. quality of life, and overall graft patency. These criteria should all be carefully weighed and evaluated for each individual prior to endovascular therapy.Table 23-26Summary of endovascular treatment strategies using device-based infrapopliteal interventionINTERVENTIONADVANTAGESDISADVANTAGESAngioplasty• Easy to use• Broad range of applications• Failure in long lesions, calcified lesions, and disease at multiple levelsBalloon-expandable stent• Overcomes arterial recoil from angioplasty• Useful in treatment of flow-limiting dissection• Crushability can lead to restenosis• Poor distal runoff can result in stent thrombosis• Limited dataSelf-expanding stent• Vessel conformability and wall apposition prevent kinking and crushing of stent• Limited sizes• Limited data; multicenter trials under wayBioabsorbable stent• Overcomes arterial recoil from angioplasty• Absorbed long term to prevent risk of stent thrombosis• Limited data; multicenter trials under wayCryoplasty• Reduces the risk of |
Surgery_Schwartz_6427 | Surgery_Schwartz | wayBioabsorbable stent• Overcomes arterial recoil from angioplasty• Absorbed long term to prevent risk of stent thrombosis• Limited data; multicenter trials under wayCryoplasty• Reduces the risk of flow-limiting dissection, therefore reducing the need for stent implantation• Short-term results of a multicenter trial are promising; however, long-term data are limitedCutting balloon• Useful in anastomotic segments of bypass grafts and in-stent restenosis where “watermelon seeding” can prevent adequate expansion of plaque• Limited dataMechanical atherectomy• Allows for debulking of plaque without the need for stent implantation in most cases• Allows for removal of plaque for histologic analysis• Limited use in areas of heavy calcification• No large, randomized, prospective trial comparing this technique to angioplasty and stentingLaser• Useful in acute thrombotic and chronic total occlusions• Minimal data in infrapopliteal arteries• Need adjunctive treatment with angioplasty, stenting, | Surgery_Schwartz. wayBioabsorbable stent• Overcomes arterial recoil from angioplasty• Absorbed long term to prevent risk of stent thrombosis• Limited data; multicenter trials under wayCryoplasty• Reduces the risk of flow-limiting dissection, therefore reducing the need for stent implantation• Short-term results of a multicenter trial are promising; however, long-term data are limitedCutting balloon• Useful in anastomotic segments of bypass grafts and in-stent restenosis where “watermelon seeding” can prevent adequate expansion of plaque• Limited dataMechanical atherectomy• Allows for debulking of plaque without the need for stent implantation in most cases• Allows for removal of plaque for histologic analysis• Limited use in areas of heavy calcification• No large, randomized, prospective trial comparing this technique to angioplasty and stentingLaser• Useful in acute thrombotic and chronic total occlusions• Minimal data in infrapopliteal arteries• Need adjunctive treatment with angioplasty, stenting, |
Surgery_Schwartz_6428 | Surgery_Schwartz | technique to angioplasty and stentingLaser• Useful in acute thrombotic and chronic total occlusions• Minimal data in infrapopliteal arteries• Need adjunctive treatment with angioplasty, stenting, or atherectomyEndovascular TreatmentTechnical Considerations. A sterile field is required in either an operating room or an angiography suite with image capabil-ity. The most common and safest access site is CFA via either a retrograde or an antegrade approach. For diagnostic angiogra-phy, arterial access should be contralateral to the symptomatic sides. For therapeutic procedures, location of the lesion and the anatomic structures of the arterial tree determine the puncture site. To avoid puncturing the iliac artery or SFA, the femoral head is located under the fluoroscopy and used as the guide for the level of needle entry. In addition, there are several useful techniques to help access a pulseless CFA including ultrasound-guided puncture, using a micropuncture kit, and targeting | Surgery_Schwartz. technique to angioplasty and stentingLaser• Useful in acute thrombotic and chronic total occlusions• Minimal data in infrapopliteal arteries• Need adjunctive treatment with angioplasty, stenting, or atherectomyEndovascular TreatmentTechnical Considerations. A sterile field is required in either an operating room or an angiography suite with image capabil-ity. The most common and safest access site is CFA via either a retrograde or an antegrade approach. For diagnostic angiogra-phy, arterial access should be contralateral to the symptomatic sides. For therapeutic procedures, location of the lesion and the anatomic structures of the arterial tree determine the puncture site. To avoid puncturing the iliac artery or SFA, the femoral head is located under the fluoroscopy and used as the guide for the level of needle entry. In addition, there are several useful techniques to help access a pulseless CFA including ultrasound-guided puncture, using a micropuncture kit, and targeting |
Surgery_Schwartz_6429 | Surgery_Schwartz | the guide for the level of needle entry. In addition, there are several useful techniques to help access a pulseless CFA including ultrasound-guided puncture, using a micropuncture kit, and targeting cal-cification in a calcified vessel. The antegrade approach may be challenging, particularly in obese patients. Meticulous technique is crucial in preventing complications, and a bony landmark can be used as guidance to ensure CFA puncture.Traversing the lesion with a wire is the most critical part of the procedure. Typically, 0.035-inch guidewires are used for femoropopliteal lesions, and 0.014or 0.018-inch guidewires are used for infrapopliteal access. Hydrophilic-coated wires, such as Glidewires, are useful in navigating through tight ste-nosis or occlusion. An angled-tip wire with a torque device may be helpful in crossing an eccentric lesion, and a shaped selective catheter is frequently used to help manipulate the wire across the lesion. The soft and floppy end of the wire is | Surgery_Schwartz. the guide for the level of needle entry. In addition, there are several useful techniques to help access a pulseless CFA including ultrasound-guided puncture, using a micropuncture kit, and targeting cal-cification in a calcified vessel. The antegrade approach may be challenging, particularly in obese patients. Meticulous technique is crucial in preventing complications, and a bony landmark can be used as guidance to ensure CFA puncture.Traversing the lesion with a wire is the most critical part of the procedure. Typically, 0.035-inch guidewires are used for femoropopliteal lesions, and 0.014or 0.018-inch guidewires are used for infrapopliteal access. Hydrophilic-coated wires, such as Glidewires, are useful in navigating through tight ste-nosis or occlusion. An angled-tip wire with a torque device may be helpful in crossing an eccentric lesion, and a shaped selective catheter is frequently used to help manipulate the wire across the lesion. The soft and floppy end of the wire is |
Surgery_Schwartz_6430 | Surgery_Schwartz | torque device may be helpful in crossing an eccentric lesion, and a shaped selective catheter is frequently used to help manipulate the wire across the lesion. The soft and floppy end of the wire is care-fully advanced crossing the lesion under fluoroscopy, and gentle force is applied while manipulating the wire. Once the lesion us traversed, one needs to pay particular attention on the tip of the wire to ensure a secure wire access and avoid vessel wall perforation or dissection.Brunicardi_Ch23_p0897-p0980.indd 96027/02/19 4:15 PM 961ARTERIAL DISEASECHAPTER 23Once the access to the diseased vessel is secured and the wire has successfully traversed the lesion, several treatment modalities can be used either alone or in conjunction with oth-ers, including angioplasty, stent or stent graft placement, and atherectomy. The available angioplasty techniques are balloon angioplasty, cryoplasty, subintimal angioplasty, and cutting bal-loon; the most commonly used atherectomy techniques | Surgery_Schwartz. torque device may be helpful in crossing an eccentric lesion, and a shaped selective catheter is frequently used to help manipulate the wire across the lesion. The soft and floppy end of the wire is care-fully advanced crossing the lesion under fluoroscopy, and gentle force is applied while manipulating the wire. Once the lesion us traversed, one needs to pay particular attention on the tip of the wire to ensure a secure wire access and avoid vessel wall perforation or dissection.Brunicardi_Ch23_p0897-p0980.indd 96027/02/19 4:15 PM 961ARTERIAL DISEASECHAPTER 23Once the access to the diseased vessel is secured and the wire has successfully traversed the lesion, several treatment modalities can be used either alone or in conjunction with oth-ers, including angioplasty, stent or stent graft placement, and atherectomy. The available angioplasty techniques are balloon angioplasty, cryoplasty, subintimal angioplasty, and cutting bal-loon; the most commonly used atherectomy techniques |
Surgery_Schwartz_6431 | Surgery_Schwartz | graft placement, and atherectomy. The available angioplasty techniques are balloon angioplasty, cryoplasty, subintimal angioplasty, and cutting bal-loon; the most commonly used atherectomy techniques include percutaneous atherectomy catheter and laser atherectomy device.Systemic anticoagulation should be maintained routinely during lower extremity arterial interventions to minimize the risk of pericatheter thrombosis. Unfractionated heparin is the most commonly used agent, administered using a weight-based formula. We typically use 80 to 100 mg/kg initial bolus for therapeutic procedure to achieve an activated clotting time above 250 seconds upon catheter insertion and administer a sub-sequent 1000 units for each additional hour of the procedure. Newer agents, such as low molecular weight heparin, platelet IIb/IIIa inhibitors, direct thrombin inhibitors, or recombinant hirudin, have been available and can be used either alone or in conjunction with heparin, particularly in patients | Surgery_Schwartz. graft placement, and atherectomy. The available angioplasty techniques are balloon angioplasty, cryoplasty, subintimal angioplasty, and cutting bal-loon; the most commonly used atherectomy techniques include percutaneous atherectomy catheter and laser atherectomy device.Systemic anticoagulation should be maintained routinely during lower extremity arterial interventions to minimize the risk of pericatheter thrombosis. Unfractionated heparin is the most commonly used agent, administered using a weight-based formula. We typically use 80 to 100 mg/kg initial bolus for therapeutic procedure to achieve an activated clotting time above 250 seconds upon catheter insertion and administer a sub-sequent 1000 units for each additional hour of the procedure. Newer agents, such as low molecular weight heparin, platelet IIb/IIIa inhibitors, direct thrombin inhibitors, or recombinant hirudin, have been available and can be used either alone or in conjunction with heparin, particularly in patients |
Surgery_Schwartz_6432 | Surgery_Schwartz | heparin, platelet IIb/IIIa inhibitors, direct thrombin inhibitors, or recombinant hirudin, have been available and can be used either alone or in conjunction with heparin, particularly in patients who are sensi-tive to unfractionated heparin. After the procedure, all patients are placed on antiplatelet therapy, such as aspirin. Additional antiplatelet agents, such as clopidogrel (Plavix), are given to selected patients with stent placement for at least 6 weeks after lower extremity interventions unless otherwise contraindicated.Percutaneous Transluminal Balloon Angioplasty. After the lesion is crossed with a wire, an appropriated balloon angio-plasty catheter is selected and tracked along the wire to traverse the lesion. The length of the selected catheter should be slightly longer than the lesion, and the diameter should be equal to the adjacent normal vessel. The balloon tends to be approximately 10% to 20% oversized. The radiopaque markers of the balloon catheter are placed so that | Surgery_Schwartz. heparin, platelet IIb/IIIa inhibitors, direct thrombin inhibitors, or recombinant hirudin, have been available and can be used either alone or in conjunction with heparin, particularly in patients who are sensi-tive to unfractionated heparin. After the procedure, all patients are placed on antiplatelet therapy, such as aspirin. Additional antiplatelet agents, such as clopidogrel (Plavix), are given to selected patients with stent placement for at least 6 weeks after lower extremity interventions unless otherwise contraindicated.Percutaneous Transluminal Balloon Angioplasty. After the lesion is crossed with a wire, an appropriated balloon angio-plasty catheter is selected and tracked along the wire to traverse the lesion. The length of the selected catheter should be slightly longer than the lesion, and the diameter should be equal to the adjacent normal vessel. The balloon tends to be approximately 10% to 20% oversized. The radiopaque markers of the balloon catheter are placed so that |
Surgery_Schwartz_6433 | Surgery_Schwartz | lesion, and the diameter should be equal to the adjacent normal vessel. The balloon tends to be approximately 10% to 20% oversized. The radiopaque markers of the balloon catheter are placed so that they will straddle the lesion. Then, the balloon is inflated with saline and contrast mixture to allow visualization of the insufflation process under the fluoroscopy (Fig. 23-65). The patient may experience mild pain, which is not uncommon. However, severe pain can be indicative of ves-sel rupture, dissection, or other complications. An angiography is crucial in confirming the intraluminal location of the catheter and absence of contrast extravasation. The inflation is continued until the waist of the atherosclerotic lesion is disappeared and the balloon is at the full profile. Frequently, several inflations are required to achieve a full profile of the balloon (Fig. 23-66). Occasionally, a lower profile balloon is needed to predilate the tight stenosis so that the selected balloon | Surgery_Schwartz. lesion, and the diameter should be equal to the adjacent normal vessel. The balloon tends to be approximately 10% to 20% oversized. The radiopaque markers of the balloon catheter are placed so that they will straddle the lesion. Then, the balloon is inflated with saline and contrast mixture to allow visualization of the insufflation process under the fluoroscopy (Fig. 23-65). The patient may experience mild pain, which is not uncommon. However, severe pain can be indicative of ves-sel rupture, dissection, or other complications. An angiography is crucial in confirming the intraluminal location of the catheter and absence of contrast extravasation. The inflation is continued until the waist of the atherosclerotic lesion is disappeared and the balloon is at the full profile. Frequently, several inflations are required to achieve a full profile of the balloon (Fig. 23-66). Occasionally, a lower profile balloon is needed to predilate the tight stenosis so that the selected balloon |
Surgery_Schwartz_6434 | Surgery_Schwartz | several inflations are required to achieve a full profile of the balloon (Fig. 23-66). Occasionally, a lower profile balloon is needed to predilate the tight stenosis so that the selected balloon catheter can cross the lesion.Besides length and diameter, the operators need to be familiar with several balloon characters. Noncompliant and low-compliant balloons tend to be inflated to their preset diam-eter and offer greater dilating force at the site of stenosis. Low-compliant balloons are the mainstay for peripheral intervention. A balloon with a low profile is used to minimize complications at the entry site and for crossing the tight lesions. Upon infla-tion, most balloons do not rewrap to their preinflation diameter and assume larger profiles. Furthermore, trackability, pushabil-ity, and crossability of the balloon should be considered when choosing a particular type of balloon. Lastly, shoulder length is an important characteristic when performing PTA to avoid injury to the | Surgery_Schwartz. several inflations are required to achieve a full profile of the balloon (Fig. 23-66). Occasionally, a lower profile balloon is needed to predilate the tight stenosis so that the selected balloon catheter can cross the lesion.Besides length and diameter, the operators need to be familiar with several balloon characters. Noncompliant and low-compliant balloons tend to be inflated to their preset diam-eter and offer greater dilating force at the site of stenosis. Low-compliant balloons are the mainstay for peripheral intervention. A balloon with a low profile is used to minimize complications at the entry site and for crossing the tight lesions. Upon infla-tion, most balloons do not rewrap to their preinflation diameter and assume larger profiles. Furthermore, trackability, pushabil-ity, and crossability of the balloon should be considered when choosing a particular type of balloon. Lastly, shoulder length is an important characteristic when performing PTA to avoid injury to the |
Surgery_Schwartz_6435 | Surgery_Schwartz | and crossability of the balloon should be considered when choosing a particular type of balloon. Lastly, shoulder length is an important characteristic when performing PTA to avoid injury to the adjacent arterial segments. After PTA, a comple-tion angiogram is performed while the wire is still in place. Leaving the wire in place provides access for repeating the pro-cedure if the result is unsatisfactory.PTA is an established and effective therapy for select patients with lower extremity occlusive diseases. Studies have shown that PTA of femoropopliteal segment achieved over 90% technical success rate and 38% to 58% 5-year primary patency rates.149,150 However, efficacy of PTA is highly dependent on anatomic selection and patient condition. PTA of lesions longer than 7 to 10 cm offers limited patency, whereas PTA of shorter lesions, such as those less than 3 cm, has fairly good results. Lofberg and associates performed 127 femoropopliteal PTA Figure 23-65. A. Angiogram demonstrating a | Surgery_Schwartz. and crossability of the balloon should be considered when choosing a particular type of balloon. Lastly, shoulder length is an important characteristic when performing PTA to avoid injury to the adjacent arterial segments. After PTA, a comple-tion angiogram is performed while the wire is still in place. Leaving the wire in place provides access for repeating the pro-cedure if the result is unsatisfactory.PTA is an established and effective therapy for select patients with lower extremity occlusive diseases. Studies have shown that PTA of femoropopliteal segment achieved over 90% technical success rate and 38% to 58% 5-year primary patency rates.149,150 However, efficacy of PTA is highly dependent on anatomic selection and patient condition. PTA of lesions longer than 7 to 10 cm offers limited patency, whereas PTA of shorter lesions, such as those less than 3 cm, has fairly good results. Lofberg and associates performed 127 femoropopliteal PTA Figure 23-65. A. Angiogram demonstrating a |
Surgery_Schwartz_6436 | Surgery_Schwartz | patency, whereas PTA of shorter lesions, such as those less than 3 cm, has fairly good results. Lofberg and associates performed 127 femoropopliteal PTA Figure 23-65. A. Angiogram demonstrating a focal stenosis in the superficial femoral artery (arrow). B. This lesion was treated with a bal-loon angioplasty catheter that inflated a dilating balloon and expanded the flow lumen. C. Completion angiogram demonstrating satisfactory radiographic result.Brunicardi_Ch23_p0897-p0980.indd 96127/02/19 4:15 PM 962SPECIFIC CONSIDERATIONSPART IIFigure 23-66. A. Angiogram demonstrating a segmental occlusion in the distal superficial femoral artery (single arrow). B. This lesion was treated with cryoplasty, which lowered the balloon catheter temperature to a temporary freezing state during the balloon angioplasty procedure (double arrows). C. Completion angiogram demonstrated satisfactory result with no evidence of vessel dissection.procedures and reported a primary 5-year success rate of 12% in | Surgery_Schwartz. patency, whereas PTA of shorter lesions, such as those less than 3 cm, has fairly good results. Lofberg and associates performed 127 femoropopliteal PTA Figure 23-65. A. Angiogram demonstrating a focal stenosis in the superficial femoral artery (arrow). B. This lesion was treated with a bal-loon angioplasty catheter that inflated a dilating balloon and expanded the flow lumen. C. Completion angiogram demonstrating satisfactory radiographic result.Brunicardi_Ch23_p0897-p0980.indd 96127/02/19 4:15 PM 962SPECIFIC CONSIDERATIONSPART IIFigure 23-66. A. Angiogram demonstrating a segmental occlusion in the distal superficial femoral artery (single arrow). B. This lesion was treated with cryoplasty, which lowered the balloon catheter temperature to a temporary freezing state during the balloon angioplasty procedure (double arrows). C. Completion angiogram demonstrated satisfactory result with no evidence of vessel dissection.procedures and reported a primary 5-year success rate of 12% in |
Surgery_Schwartz_6437 | Surgery_Schwartz | angioplasty procedure (double arrows). C. Completion angiogram demonstrated satisfactory result with no evidence of vessel dissection.procedures and reported a primary 5-year success rate of 12% in limbs with occlusion longer than 5 cm versus 32% in limbs with occlusion less than 5 cm in length.151 Occlusive lesions have much worse initial technical success rates than stenotic lesions. Concentric lesions respond better to PTA than eccentric lesions, and heavy calcifications have a negative impact on success rates. A meta-analysis by Hunink and associates showed that adjusted 5-year primary patencies after angioplasty of femoropopliteal lesions varied from 12% to 68%, with the best results being for patients with claudication and stenotic lesions.152 Distal runoff is another powerful predictor of long-term success. Johnston analyzed 254 consecutive patients who underwent femoral and popliteal PTA and reported a 5-year patency rate of 53% for ste-notic lesions and 36% for occlusive | Surgery_Schwartz. angioplasty procedure (double arrows). C. Completion angiogram demonstrated satisfactory result with no evidence of vessel dissection.procedures and reported a primary 5-year success rate of 12% in limbs with occlusion longer than 5 cm versus 32% in limbs with occlusion less than 5 cm in length.151 Occlusive lesions have much worse initial technical success rates than stenotic lesions. Concentric lesions respond better to PTA than eccentric lesions, and heavy calcifications have a negative impact on success rates. A meta-analysis by Hunink and associates showed that adjusted 5-year primary patencies after angioplasty of femoropopliteal lesions varied from 12% to 68%, with the best results being for patients with claudication and stenotic lesions.152 Distal runoff is another powerful predictor of long-term success. Johnston analyzed 254 consecutive patients who underwent femoral and popliteal PTA and reported a 5-year patency rate of 53% for ste-notic lesions and 36% for occlusive |
Surgery_Schwartz_6438 | Surgery_Schwartz | of long-term success. Johnston analyzed 254 consecutive patients who underwent femoral and popliteal PTA and reported a 5-year patency rate of 53% for ste-notic lesions and 36% for occlusive lesions in patients with good runoff versus a 5-year patency rate of 31% for stenotic lesions and 16% for occlusive lesions in patients with poor runoff.149 Literature reviews showed that 5-year patency rates varied from 27% to 67% based on runoff status.152Due to limited success with infrapopliteal PTA, the indi-cation for infrapopliteal PTA is stringent and reserved for limb salvage. Current patency rates from infrapopliteal PTA can be improved further by proper patient selection, ensuring straight-line flow to the foot in at least one tibial vessel, and close patient surveillance for early reintervention. Possible future advances, including the use of drug-eluting stents, cutting balloons, and atherectomy devices, are being investigated to improve clini-cal outcomes following endovascular | Surgery_Schwartz. of long-term success. Johnston analyzed 254 consecutive patients who underwent femoral and popliteal PTA and reported a 5-year patency rate of 53% for ste-notic lesions and 36% for occlusive lesions in patients with good runoff versus a 5-year patency rate of 31% for stenotic lesions and 16% for occlusive lesions in patients with poor runoff.149 Literature reviews showed that 5-year patency rates varied from 27% to 67% based on runoff status.152Due to limited success with infrapopliteal PTA, the indi-cation for infrapopliteal PTA is stringent and reserved for limb salvage. Current patency rates from infrapopliteal PTA can be improved further by proper patient selection, ensuring straight-line flow to the foot in at least one tibial vessel, and close patient surveillance for early reintervention. Possible future advances, including the use of drug-eluting stents, cutting balloons, and atherectomy devices, are being investigated to improve clini-cal outcomes following endovascular |
Surgery_Schwartz_6439 | Surgery_Schwartz | Possible future advances, including the use of drug-eluting stents, cutting balloons, and atherectomy devices, are being investigated to improve clini-cal outcomes following endovascular interventions on the tibial arteries. Varty and associates reported a 1-year limb salvage rate of 77% in patients with critical ischemia who underwent infrapopliteal PTA.153 In patients with favorable anatomies, the 2-year limb salvage rate after infrapopliteal PTA is expected to exceed 80%.Subintimal Angioplasty. The technique of subintimal angio-plasty was first described in 1987 when successful establish-ment of flow was made by accidental creation of a subintimal channel during treatment of a long popliteal artery occlusion. Subintimal angioplasty is recommended for chronic occlusion, long segment of lesion, and heavily calcified lesions. In addi-tion, this technique is applicable for vessels with diffuse dis-ease and for vessels that had previously failed an intraluminal approach, when it is | Surgery_Schwartz. Possible future advances, including the use of drug-eluting stents, cutting balloons, and atherectomy devices, are being investigated to improve clini-cal outcomes following endovascular interventions on the tibial arteries. Varty and associates reported a 1-year limb salvage rate of 77% in patients with critical ischemia who underwent infrapopliteal PTA.153 In patients with favorable anatomies, the 2-year limb salvage rate after infrapopliteal PTA is expected to exceed 80%.Subintimal Angioplasty. The technique of subintimal angio-plasty was first described in 1987 when successful establish-ment of flow was made by accidental creation of a subintimal channel during treatment of a long popliteal artery occlusion. Subintimal angioplasty is recommended for chronic occlusion, long segment of lesion, and heavily calcified lesions. In addi-tion, this technique is applicable for vessels with diffuse dis-ease and for vessels that had previously failed an intraluminal approach, when it is |
Surgery_Schwartz_6440 | Surgery_Schwartz | of lesion, and heavily calcified lesions. In addi-tion, this technique is applicable for vessels with diffuse dis-ease and for vessels that had previously failed an intraluminal approach, when it is difficult to negotiate the wire across the entire diseased segment without dissection.The principle of this technique is to bypass the occlusion by deliberately creating a subintimal dissection plan commenc-ing proximal to the lesion and continuing in the subintimal space before retry into the true lumen distal to the lesion. The occluded lumen is recanalized through the subintimal plan. Sub-intimal angioplasty can be performed through either an ipsilat-eral antegrade or contralateral retrograde approach using the CFA approach. If selecting contralateral CFA puncture, a long guiding sheath is placed across the aortic bifurcation to provide access for the femoropopliteal and infrapopliteal vessels. The subintimal dissection is initiated at the origin of an occlusion by directing the tip of | Surgery_Schwartz. of lesion, and heavily calcified lesions. In addi-tion, this technique is applicable for vessels with diffuse dis-ease and for vessels that had previously failed an intraluminal approach, when it is difficult to negotiate the wire across the entire diseased segment without dissection.The principle of this technique is to bypass the occlusion by deliberately creating a subintimal dissection plan commenc-ing proximal to the lesion and continuing in the subintimal space before retry into the true lumen distal to the lesion. The occluded lumen is recanalized through the subintimal plan. Sub-intimal angioplasty can be performed through either an ipsilat-eral antegrade or contralateral retrograde approach using the CFA approach. If selecting contralateral CFA puncture, a long guiding sheath is placed across the aortic bifurcation to provide access for the femoropopliteal and infrapopliteal vessels. The subintimal dissection is initiated at the origin of an occlusion by directing the tip of |
Surgery_Schwartz_6441 | Surgery_Schwartz | placed across the aortic bifurcation to provide access for the femoropopliteal and infrapopliteal vessels. The subintimal dissection is initiated at the origin of an occlusion by directing the tip of an angled guide wire, usually an angled hydrophilic wire, such as a Glidewire. A supporting catheter is used to guide the tip of the guidewire away from the impor-tant collaterals. When the wire is advanced, a loop is naturally formed at the tip of the guidewire. Once the subintimal plan is entered, the wire tends to move freely in dissection space. Sub-intimal location of the wire and the catheter can be confirmed by injecting a small amount of diluted contrast. At this point, the wire and the catheter are then advanced along the subintimal plan until the occlusion segment is passed. A loss of resistance is often encountered as the guidewire reenters the true lumen distal to the occlusion. Recanalization is confirmed by advanc-ing the catheter over the guidewire beyond the point of | Surgery_Schwartz. placed across the aortic bifurcation to provide access for the femoropopliteal and infrapopliteal vessels. The subintimal dissection is initiated at the origin of an occlusion by directing the tip of an angled guide wire, usually an angled hydrophilic wire, such as a Glidewire. A supporting catheter is used to guide the tip of the guidewire away from the impor-tant collaterals. When the wire is advanced, a loop is naturally formed at the tip of the guidewire. Once the subintimal plan is entered, the wire tends to move freely in dissection space. Sub-intimal location of the wire and the catheter can be confirmed by injecting a small amount of diluted contrast. At this point, the wire and the catheter are then advanced along the subintimal plan until the occlusion segment is passed. A loss of resistance is often encountered as the guidewire reenters the true lumen distal to the occlusion. Recanalization is confirmed by advanc-ing the catheter over the guidewire beyond the point of |
Surgery_Schwartz_6442 | Surgery_Schwartz | loss of resistance is often encountered as the guidewire reenters the true lumen distal to the occlusion. Recanalization is confirmed by advanc-ing the catheter over the guidewire beyond the point of reen-try and obtaining an angiogram. This is followed by a balloon angioplasty. To confirm the patency following balloon dilata-tion, a completion angiogram is performed prior to withdraw-ing the catheter and wire. If flow is impaired, repeat balloon Brunicardi_Ch23_p0897-p0980.indd 96227/02/19 4:15 PM 963ARTERIAL DISEASECHAPTER 23dilatation may be necessary. Frequently, a stent is required to maintain a patent lumen and treat residual stenosis if more than 30% luminal reduction is confirmed on completion angiogram.Multiple studies have demonstrated the efficacy of subin-timal angioplasty. Bolia and colleagues reported their extensive experiences on subintimal angioplasty for treating long-segment occlusions of infrainguinal vessels.154 They achieved a techni-cal success rate of over | Surgery_Schwartz. loss of resistance is often encountered as the guidewire reenters the true lumen distal to the occlusion. Recanalization is confirmed by advanc-ing the catheter over the guidewire beyond the point of reen-try and obtaining an angiogram. This is followed by a balloon angioplasty. To confirm the patency following balloon dilata-tion, a completion angiogram is performed prior to withdraw-ing the catheter and wire. If flow is impaired, repeat balloon Brunicardi_Ch23_p0897-p0980.indd 96227/02/19 4:15 PM 963ARTERIAL DISEASECHAPTER 23dilatation may be necessary. Frequently, a stent is required to maintain a patent lumen and treat residual stenosis if more than 30% luminal reduction is confirmed on completion angiogram.Multiple studies have demonstrated the efficacy of subin-timal angioplasty. Bolia and colleagues reported their extensive experiences on subintimal angioplasty for treating long-segment occlusions of infrainguinal vessels.154 They achieved a techni-cal success rate of over |
Surgery_Schwartz_6443 | Surgery_Schwartz | Bolia and colleagues reported their extensive experiences on subintimal angioplasty for treating long-segment occlusions of infrainguinal vessels.154 They achieved a techni-cal success rate of over 80% for both femoropopliteal and tibial arteries. One-year patency rates varied from 53% for infrapopli-teal vessels to 71% for femoropopliteal segments. Limb salvage rates reached over 80% at 12 months. They also reported that the factors influencing patency are smoking, number of runoff vessels, and occlusion length. Studies by other groups showed similar results.155 Treiman and colleagues treated 25 patients with 6to 18-cm femoropopliteal occlusion and achieved a technical success rate of 92% and a 13-month primary patency rate of 92%,156 whereas Lipsitz and associates reported a techni-cal success rate of 87% in 39 treated patients and a 12-month cumulative patency rate of 74%.155 In addition, Ingle and asso-ciates reported a technical success rate of 87% in 67 patients with | Surgery_Schwartz. Bolia and colleagues reported their extensive experiences on subintimal angioplasty for treating long-segment occlusions of infrainguinal vessels.154 They achieved a techni-cal success rate of over 80% for both femoropopliteal and tibial arteries. One-year patency rates varied from 53% for infrapopli-teal vessels to 71% for femoropopliteal segments. Limb salvage rates reached over 80% at 12 months. They also reported that the factors influencing patency are smoking, number of runoff vessels, and occlusion length. Studies by other groups showed similar results.155 Treiman and colleagues treated 25 patients with 6to 18-cm femoropopliteal occlusion and achieved a technical success rate of 92% and a 13-month primary patency rate of 92%,156 whereas Lipsitz and associates reported a techni-cal success rate of 87% in 39 treated patients and a 12-month cumulative patency rate of 74%.155 In addition, Ingle and asso-ciates reported a technical success rate of 87% in 67 patients with |
Surgery_Schwartz_6444 | Surgery_Schwartz | techni-cal success rate of 87% in 39 treated patients and a 12-month cumulative patency rate of 74%.155 In addition, Ingle and asso-ciates reported a technical success rate of 87% in 67 patients with femoropopliteal lesions and a 36-month limb salvage rate of 94%.157 As demonstrated herein, although technical success rates are similar in most series, the patency rates vary widely in different studies. Patient selection, anatomic character, and lesion locations may account for the wide range of outcomes.Stent Placement. Although suggested by Dotter during the late 1960s, the use of an endoluminal stent was not pursued until the limitations of PTA were widely recognized. There are sev-eral situations where stent placement is appealing. The primary indication is the potential salvage of an unacceptable angio-plasty result. Stent placement is typically used when residual stenosis after PTA is 30% or greater. An endoluminal stent is also used for dissection, perforation, and other PTA | Surgery_Schwartz. techni-cal success rate of 87% in 39 treated patients and a 12-month cumulative patency rate of 74%.155 In addition, Ingle and asso-ciates reported a technical success rate of 87% in 67 patients with femoropopliteal lesions and a 36-month limb salvage rate of 94%.157 As demonstrated herein, although technical success rates are similar in most series, the patency rates vary widely in different studies. Patient selection, anatomic character, and lesion locations may account for the wide range of outcomes.Stent Placement. Although suggested by Dotter during the late 1960s, the use of an endoluminal stent was not pursued until the limitations of PTA were widely recognized. There are sev-eral situations where stent placement is appealing. The primary indication is the potential salvage of an unacceptable angio-plasty result. Stent placement is typically used when residual stenosis after PTA is 30% or greater. An endoluminal stent is also used for dissection, perforation, and other PTA |
Surgery_Schwartz_6445 | Surgery_Schwartz | an unacceptable angio-plasty result. Stent placement is typically used when residual stenosis after PTA is 30% or greater. An endoluminal stent is also used for dissection, perforation, and other PTA complica-tions. Primary stent placement has become a viable alternative for treating ulcerative lesions that may potentially be the source for embolization. Primary stent is also used to treat occlusive lesions that have a tendency for reocclusion and distal emboliza-tion after PTA. In addition, an endoluminal stent is potentially beneficial for early restenosis after PTA. Drug-eluting stents are currently under investigation in the United States and may be promising in decreasing restenosis rates.Although technical success rates are high, published series on femoropopliteal artery stents show that patency rates are comparable to PTA alone, with primary patency rates vary-ing from 18% to 72% at 3 years.158 Gray and associates stented 58 limbs after suboptimal PTA for long SFA lesions and | Surgery_Schwartz. an unacceptable angio-plasty result. Stent placement is typically used when residual stenosis after PTA is 30% or greater. An endoluminal stent is also used for dissection, perforation, and other PTA complica-tions. Primary stent placement has become a viable alternative for treating ulcerative lesions that may potentially be the source for embolization. Primary stent is also used to treat occlusive lesions that have a tendency for reocclusion and distal emboliza-tion after PTA. In addition, an endoluminal stent is potentially beneficial for early restenosis after PTA. Drug-eluting stents are currently under investigation in the United States and may be promising in decreasing restenosis rates.Although technical success rates are high, published series on femoropopliteal artery stents show that patency rates are comparable to PTA alone, with primary patency rates vary-ing from 18% to 72% at 3 years.158 Gray and associates stented 58 limbs after suboptimal PTA for long SFA lesions and |
Surgery_Schwartz_6446 | Surgery_Schwartz | that patency rates are comparable to PTA alone, with primary patency rates vary-ing from 18% to 72% at 3 years.158 Gray and associates stented 58 limbs after suboptimal PTA for long SFA lesions and dem-onstrated a 1-year primary patency rate of 22%.159 However, Mewissen treated 137 limbs using self-expanding SMART niti-nol stents in patients with TASC A, B, and C femoropopliteal lesions and reported a 1-year primary patency of 76% and a 24-month primary patency rate of 60%.160 Appropriate patient selection and the anatomic characteristics of the lesions are cru-cial in the success of treatment outcomes. Additionally, stent characteristics may contribute to the patency rate.Several clinical studies have demonstrated the significant improvements of the new generation of nitinol stents for the SFA lesions: the German Multicenter Experience, the Mewis-sen trial, the BLASTER Trial, and the SIROCCO trial.161 The German Multicenter Experience was a retrospective review of 111 SFA stenting | Surgery_Schwartz. that patency rates are comparable to PTA alone, with primary patency rates vary-ing from 18% to 72% at 3 years.158 Gray and associates stented 58 limbs after suboptimal PTA for long SFA lesions and dem-onstrated a 1-year primary patency rate of 22%.159 However, Mewissen treated 137 limbs using self-expanding SMART niti-nol stents in patients with TASC A, B, and C femoropopliteal lesions and reported a 1-year primary patency of 76% and a 24-month primary patency rate of 60%.160 Appropriate patient selection and the anatomic characteristics of the lesions are cru-cial in the success of treatment outcomes. Additionally, stent characteristics may contribute to the patency rate.Several clinical studies have demonstrated the significant improvements of the new generation of nitinol stents for the SFA lesions: the German Multicenter Experience, the Mewis-sen trial, the BLASTER Trial, and the SIROCCO trial.161 The German Multicenter Experience was a retrospective review of 111 SFA stenting |
Surgery_Schwartz_6447 | Surgery_Schwartz | the SFA lesions: the German Multicenter Experience, the Mewis-sen trial, the BLASTER Trial, and the SIROCCO trial.161 The German Multicenter Experience was a retrospective review of 111 SFA stenting procedures and predicted that the 6-month patency rate for SMART stents was 82% versus 37% for the Wallstent. The BLASTER (Bilateral Lower Arterial Stenting Employing Reopro) Trial evaluated the feasibility of using nitinol stents with and without intravenous abciximab for the treatment of femoral artery disease, and the preliminary results showed a 1-year clinical patency rate of 83%.162Furthermore, the drug-eluting stent, which proved effec-tive in decreasing restenosis in coronary intervention, may offer another promising alternative in lower extremity diseases. The drug released over a period of time interferes with smooth mus-cle cell proliferation, the main cellular element and source of extracellular matrix–producing restenosis. The first drug-eluting stent clinical trial used | Surgery_Schwartz. the SFA lesions: the German Multicenter Experience, the Mewis-sen trial, the BLASTER Trial, and the SIROCCO trial.161 The German Multicenter Experience was a retrospective review of 111 SFA stenting procedures and predicted that the 6-month patency rate for SMART stents was 82% versus 37% for the Wallstent. The BLASTER (Bilateral Lower Arterial Stenting Employing Reopro) Trial evaluated the feasibility of using nitinol stents with and without intravenous abciximab for the treatment of femoral artery disease, and the preliminary results showed a 1-year clinical patency rate of 83%.162Furthermore, the drug-eluting stent, which proved effec-tive in decreasing restenosis in coronary intervention, may offer another promising alternative in lower extremity diseases. The drug released over a period of time interferes with smooth mus-cle cell proliferation, the main cellular element and source of extracellular matrix–producing restenosis. The first drug-eluting stent clinical trial used |
Surgery_Schwartz_6448 | Surgery_Schwartz | a period of time interferes with smooth mus-cle cell proliferation, the main cellular element and source of extracellular matrix–producing restenosis. The first drug-eluting stent clinical trial used Cordis Cypher SMART stents coated with sirolimus (SIROCCO trial).163 The SIROCCO results showed binary in-lesion restenosis rates of 0% in the sirolimus-eluting group versus 23.5% in the noneluting group at 6-month follow-up angiography. The PaRADISE (Preventing Amputa-tions Using Drug-Eluting Stents) Trial investigated the efficacy and safety of using balloon-expandable drug-eluting stents to prevent amputations in patients with below-the-knee critical limb ischemia.164 One hundred six patients (118 limbs) were treated with drug-eluting stents in this prospective, nonrandom-ized trial. There were 228 drug-eluting stents implanted (83% Cypher [Cordis, Johnson & Johnson, Warren, NJ], 17% Taxus [Boston Scientific, Maple Grove, MN]). The average length treated was 60 mm. The 3-year | Surgery_Schwartz. a period of time interferes with smooth mus-cle cell proliferation, the main cellular element and source of extracellular matrix–producing restenosis. The first drug-eluting stent clinical trial used Cordis Cypher SMART stents coated with sirolimus (SIROCCO trial).163 The SIROCCO results showed binary in-lesion restenosis rates of 0% in the sirolimus-eluting group versus 23.5% in the noneluting group at 6-month follow-up angiography. The PaRADISE (Preventing Amputa-tions Using Drug-Eluting Stents) Trial investigated the efficacy and safety of using balloon-expandable drug-eluting stents to prevent amputations in patients with below-the-knee critical limb ischemia.164 One hundred six patients (118 limbs) were treated with drug-eluting stents in this prospective, nonrandom-ized trial. There were 228 drug-eluting stents implanted (83% Cypher [Cordis, Johnson & Johnson, Warren, NJ], 17% Taxus [Boston Scientific, Maple Grove, MN]). The average length treated was 60 mm. The 3-year |
Surgery_Schwartz_6449 | Surgery_Schwartz | There were 228 drug-eluting stents implanted (83% Cypher [Cordis, Johnson & Johnson, Warren, NJ], 17% Taxus [Boston Scientific, Maple Grove, MN]). The average length treated was 60 mm. The 3-year cumulative incidence of amputa-tion was 6%, the survival rate was 71%, and the amputation-free survival rate was 68%. Only 12% of patients who died had a preceding major amputation. Rutherford category, age, creati-nine level, and dialysis were predictors of death but not amputa-tion. Target limb revascularization occurred in 15% of patients.Stent Graft. The concept of endoluminal bypass using stent graft in treating atherosclerotic SFA disease has been enter-tained. A stent graft is placed percutaneously across a long segment or multiple segments of lesions and is used to create a femoropopliteal bypass. Theoretically, endobypass has the potential of being as successful as surgical bypass graft by relin-ing the vessel wall in its anatomic position without the nega-tive impact of anastomosis. | Surgery_Schwartz. There were 228 drug-eluting stents implanted (83% Cypher [Cordis, Johnson & Johnson, Warren, NJ], 17% Taxus [Boston Scientific, Maple Grove, MN]). The average length treated was 60 mm. The 3-year cumulative incidence of amputa-tion was 6%, the survival rate was 71%, and the amputation-free survival rate was 68%. Only 12% of patients who died had a preceding major amputation. Rutherford category, age, creati-nine level, and dialysis were predictors of death but not amputa-tion. Target limb revascularization occurred in 15% of patients.Stent Graft. The concept of endoluminal bypass using stent graft in treating atherosclerotic SFA disease has been enter-tained. A stent graft is placed percutaneously across a long segment or multiple segments of lesions and is used to create a femoropopliteal bypass. Theoretically, endobypass has the potential of being as successful as surgical bypass graft by relin-ing the vessel wall in its anatomic position without the nega-tive impact of anastomosis. |
Surgery_Schwartz_6450 | Surgery_Schwartz | bypass. Theoretically, endobypass has the potential of being as successful as surgical bypass graft by relin-ing the vessel wall in its anatomic position without the nega-tive impact of anastomosis. Stent grafts can be divided into two categories: unsupported and fully supported. The unsupported grafts consist of segments of bypass graft, such as PTFE, with an expandable stent at one or both ends. The unsupported grafts are flexible with a low profile, but prone to external compres-sion. The supported stent grafts consist of a metallic skeleton covered with graft fabric. The presence of a dense metal skele-ton promotes an extensive inflammatory response and increases the risk of thrombosis. There is no FDA-approved stent graft for peripheral intervention. However, Viabahn (WL Gore & Associates, Flagstaff, AZ) is the most commonly used device in the United States and is composed of an ultra-thin PTFE graft externally supported by self-expanding nitinol meshwork. The Viabahn device has | Surgery_Schwartz. bypass. Theoretically, endobypass has the potential of being as successful as surgical bypass graft by relin-ing the vessel wall in its anatomic position without the nega-tive impact of anastomosis. Stent grafts can be divided into two categories: unsupported and fully supported. The unsupported grafts consist of segments of bypass graft, such as PTFE, with an expandable stent at one or both ends. The unsupported grafts are flexible with a low profile, but prone to external compres-sion. The supported stent grafts consist of a metallic skeleton covered with graft fabric. The presence of a dense metal skele-ton promotes an extensive inflammatory response and increases the risk of thrombosis. There is no FDA-approved stent graft for peripheral intervention. However, Viabahn (WL Gore & Associates, Flagstaff, AZ) is the most commonly used device in the United States and is composed of an ultra-thin PTFE graft externally supported by self-expanding nitinol meshwork. The Viabahn device has |
Surgery_Schwartz_6451 | Surgery_Schwartz | Flagstaff, AZ) is the most commonly used device in the United States and is composed of an ultra-thin PTFE graft externally supported by self-expanding nitinol meshwork. The Viabahn device has a specific delivery mechanism by pulling back the attached string, which results in proximal-to-distal delivery of the endoprosthesis.Although it is an intriguing concept, data on endobypass results are limited, and the graft thrombosis rate is high. Addi-tionally, covering major collateral vessels can potentially jeop-ardize the viability of the limb if stent graft occlusion occurs. Bauermeister treated 35 patients with Hemobahn and reported a 28.6% occlusion rate at an average 7-month follow-up.165 Kedora and colleagues recently conducted a prospective, randomized study comparing covered PTFE/nitinol self-expanding stent grafts with prosthetic above-the-knee femoropopliteal bypass. Fifty limbs were randomized into each group. Primary patency Brunicardi_Ch23_p0897-p0980.indd 96327/02/19 | Surgery_Schwartz. Flagstaff, AZ) is the most commonly used device in the United States and is composed of an ultra-thin PTFE graft externally supported by self-expanding nitinol meshwork. The Viabahn device has a specific delivery mechanism by pulling back the attached string, which results in proximal-to-distal delivery of the endoprosthesis.Although it is an intriguing concept, data on endobypass results are limited, and the graft thrombosis rate is high. Addi-tionally, covering major collateral vessels can potentially jeop-ardize the viability of the limb if stent graft occlusion occurs. Bauermeister treated 35 patients with Hemobahn and reported a 28.6% occlusion rate at an average 7-month follow-up.165 Kedora and colleagues recently conducted a prospective, randomized study comparing covered PTFE/nitinol self-expanding stent grafts with prosthetic above-the-knee femoropopliteal bypass. Fifty limbs were randomized into each group. Primary patency Brunicardi_Ch23_p0897-p0980.indd 96327/02/19 |
Surgery_Schwartz_6452 | Surgery_Schwartz | self-expanding stent grafts with prosthetic above-the-knee femoropopliteal bypass. Fifty limbs were randomized into each group. Primary patency Brunicardi_Ch23_p0897-p0980.indd 96327/02/19 4:15 PM 964SPECIFIC CONSIDERATIONSPART IIat 1 year was approximately 74% for both cohorts, with a mean follow-up of 18 months. The covered nitinol/PTFE stent graft in the SFA had a 1-year patency comparable to surgical bypass, with a significantly shorter hospital stay (0.9 vs. 3.1 days).166 A recent randomized prospective study comparing the treatment of SFA occlusive disease percutaneously with an expanded PTFE (ePTFE)/nitinol self-expanding stent graft (stent graft) versus surgical femoral to above-knee popliteal artery bypass with synthetic graft material showed no difference between the two groups with respect to primary or secondary patency rates at 48 months.167 Mean total lesion length of the treated arterial seg-ment in the stent graft group was 25.6 cm. The stent graft group | Surgery_Schwartz. self-expanding stent grafts with prosthetic above-the-knee femoropopliteal bypass. Fifty limbs were randomized into each group. Primary patency Brunicardi_Ch23_p0897-p0980.indd 96327/02/19 4:15 PM 964SPECIFIC CONSIDERATIONSPART IIat 1 year was approximately 74% for both cohorts, with a mean follow-up of 18 months. The covered nitinol/PTFE stent graft in the SFA had a 1-year patency comparable to surgical bypass, with a significantly shorter hospital stay (0.9 vs. 3.1 days).166 A recent randomized prospective study comparing the treatment of SFA occlusive disease percutaneously with an expanded PTFE (ePTFE)/nitinol self-expanding stent graft (stent graft) versus surgical femoral to above-knee popliteal artery bypass with synthetic graft material showed no difference between the two groups with respect to primary or secondary patency rates at 48 months.167 Mean total lesion length of the treated arterial seg-ment in the stent graft group was 25.6 cm. The stent graft group |
Surgery_Schwartz_6453 | Surgery_Schwartz | two groups with respect to primary or secondary patency rates at 48 months.167 Mean total lesion length of the treated arterial seg-ment in the stent graft group was 25.6 cm. The stent graft group demonstrated a primary patency of 72%, 63%, 63%, and 59% with a secondary patency of 83%, 74%, 74%, and 74% at 12, 24, 36, and 48 months, respectively. The surgical femoral-popliteal group demonstrated a primary patency of 76%, 63%, 63%, and 58% with a secondary patency of 86%, 76%, 76%, and 71% at 12, 24, 36, and 48 months, respectively. The authors concluded that ePTFE/nitinol self-expanding stent graft placement can be offered as an alternative to treatment of the SFA segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable.Atherectomy. The basic principle of atherectomy is to remove the atheroma from obstructed arterial vessels. The currently available atherectomy devices can be generally categorized into directional, | Surgery_Schwartz. two groups with respect to primary or secondary patency rates at 48 months.167 Mean total lesion length of the treated arterial seg-ment in the stent graft group was 25.6 cm. The stent graft group demonstrated a primary patency of 72%, 63%, 63%, and 59% with a secondary patency of 83%, 74%, 74%, and 74% at 12, 24, 36, and 48 months, respectively. The surgical femoral-popliteal group demonstrated a primary patency of 76%, 63%, 63%, and 58% with a secondary patency of 86%, 76%, 76%, and 71% at 12, 24, 36, and 48 months, respectively. The authors concluded that ePTFE/nitinol self-expanding stent graft placement can be offered as an alternative to treatment of the SFA segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable.Atherectomy. The basic principle of atherectomy is to remove the atheroma from obstructed arterial vessels. The currently available atherectomy devices can be generally categorized into directional, |
Surgery_Schwartz_6454 | Surgery_Schwartz | basic principle of atherectomy is to remove the atheroma from obstructed arterial vessels. The currently available atherectomy devices can be generally categorized into directional, nondirectional, orbital, and rotational types based on their mechanism. A few examples of FDA-approved atherectomy devices are Simpson AtheroCath (DVI, Redwood City, CA), Transluminal Extraction Catheter (Interventional Technologies, San Diego, CA), Thoratec recanalization arterial catheter (Thoratec, Pleasanton, CA), Auth Rotablator (Heart Technologies, Redmond, WA), SilverHawk system (FoxHollow Technologies, Redwood City, CA), Jetstream atherectomy sys-tem (Bayer, Indianola, PA), Diamondback 360° orbital atherec-tomy device (Cardiovascular Systems, Inc, St. Paul, MN), and Rotablator system (Boston Scientific Corporation, Natick, MA). These devices either cut and remove or pulverize the atheroma plaques.The Simpson AtheroCath has a directional cutting ele-ment that is exposed to one-third of the | Surgery_Schwartz. basic principle of atherectomy is to remove the atheroma from obstructed arterial vessels. The currently available atherectomy devices can be generally categorized into directional, nondirectional, orbital, and rotational types based on their mechanism. A few examples of FDA-approved atherectomy devices are Simpson AtheroCath (DVI, Redwood City, CA), Transluminal Extraction Catheter (Interventional Technologies, San Diego, CA), Thoratec recanalization arterial catheter (Thoratec, Pleasanton, CA), Auth Rotablator (Heart Technologies, Redmond, WA), SilverHawk system (FoxHollow Technologies, Redwood City, CA), Jetstream atherectomy sys-tem (Bayer, Indianola, PA), Diamondback 360° orbital atherec-tomy device (Cardiovascular Systems, Inc, St. Paul, MN), and Rotablator system (Boston Scientific Corporation, Natick, MA). These devices either cut and remove or pulverize the atheroma plaques.The Simpson AtheroCath has a directional cutting ele-ment that is exposed to one-third of the |
Surgery_Schwartz_6455 | Surgery_Schwartz | Corporation, Natick, MA). These devices either cut and remove or pulverize the atheroma plaques.The Simpson AtheroCath has a directional cutting ele-ment that is exposed to one-third of the circumference of the arterial wall. The atheroma protruding into the window is excised and pushed into the collection chamber. The Translu-minal Extraction Catheter has an over-the-wire nondirectional cutter mounted on the distal end of a torque tube. The excised atheroma is simultaneously removed by aspiration through the torque tube. The Thoratec recanalization arterial catheter is a nondirectional, noncoaxial, atheroablative device. The rotating cam tip pulverizes the atheromatous lesion into minute particles. The Auth Rotablator is a nondirectional, coaxial, atheroablative device with a metal burr embedded with fine diamond chips. SilverHawk device is a monorail catheter designed to overcome the drawbacks of a directional atherectomy catheter. The work-ing end consists of a hinged housing unit | Surgery_Schwartz. Corporation, Natick, MA). These devices either cut and remove or pulverize the atheroma plaques.The Simpson AtheroCath has a directional cutting ele-ment that is exposed to one-third of the circumference of the arterial wall. The atheroma protruding into the window is excised and pushed into the collection chamber. The Translu-minal Extraction Catheter has an over-the-wire nondirectional cutter mounted on the distal end of a torque tube. The excised atheroma is simultaneously removed by aspiration through the torque tube. The Thoratec recanalization arterial catheter is a nondirectional, noncoaxial, atheroablative device. The rotating cam tip pulverizes the atheromatous lesion into minute particles. The Auth Rotablator is a nondirectional, coaxial, atheroablative device with a metal burr embedded with fine diamond chips. SilverHawk device is a monorail catheter designed to overcome the drawbacks of a directional atherectomy catheter. The work-ing end consists of a hinged housing unit |
Surgery_Schwartz_6456 | Surgery_Schwartz | embedded with fine diamond chips. SilverHawk device is a monorail catheter designed to overcome the drawbacks of a directional atherectomy catheter. The work-ing end consists of a hinged housing unit containing a carbide cutting blade. The blade is activated from the motor drive unit, and the catheter is then advanced through the length of the lesion. Once each pass is completed, the cutter then packs the tissue into the distal end of the nosecone to maximize collec-tion capacity. The SilverHawk can then either be removed or torqued to treat a different quadrant in the same lesion or other lesions. Jetstream atherectomy system is a rotating, aspirat-ing catheter with tip sizes of 1.6 and 1.8 mm for tibial arteries, and an expandable catheter with a tip size ranging from 2.1 to 3.4 mm for active removal of atherosclerotic debris and throm-bus. The Diamondback 360° orbital atherectomy device uses a drive shaft with an eccentrically mounted, diamond-coated crown to create an orbital | Surgery_Schwartz. embedded with fine diamond chips. SilverHawk device is a monorail catheter designed to overcome the drawbacks of a directional atherectomy catheter. The work-ing end consists of a hinged housing unit containing a carbide cutting blade. The blade is activated from the motor drive unit, and the catheter is then advanced through the length of the lesion. Once each pass is completed, the cutter then packs the tissue into the distal end of the nosecone to maximize collec-tion capacity. The SilverHawk can then either be removed or torqued to treat a different quadrant in the same lesion or other lesions. Jetstream atherectomy system is a rotating, aspirat-ing catheter with tip sizes of 1.6 and 1.8 mm for tibial arteries, and an expandable catheter with a tip size ranging from 2.1 to 3.4 mm for active removal of atherosclerotic debris and throm-bus. The Diamondback 360° orbital atherectomy device uses a drive shaft with an eccentrically mounted, diamond-coated crown to create an orbital |
Surgery_Schwartz_6457 | Surgery_Schwartz | for active removal of atherosclerotic debris and throm-bus. The Diamondback 360° orbital atherectomy device uses a drive shaft with an eccentrically mounted, diamond-coated crown to create an orbital spin. As the speed of the crown increases from centrifugal force, it sands wider spaces, thereby providing variability in its working range. It can create a lumen that is >1.75 times the crossing profile depending on the size of the grit and the eccentricity of the offset. The greater the speed of the crown, the larger is the arc of debulking and, ultimately, the resultant lumen size. A constant flow of saline solution is delivered by a roller pump that lubricates the device and helps to flush the debris. The Rotablator system high-speed rotational device uses calcium ablation to achieve larger lumens. It has been used for more than 20 years to treat challenging, calcified coronary artery disease. The diamond-coated burr is designed to preferentially engage calcium and modify lesion | Surgery_Schwartz. for active removal of atherosclerotic debris and throm-bus. The Diamondback 360° orbital atherectomy device uses a drive shaft with an eccentrically mounted, diamond-coated crown to create an orbital spin. As the speed of the crown increases from centrifugal force, it sands wider spaces, thereby providing variability in its working range. It can create a lumen that is >1.75 times the crossing profile depending on the size of the grit and the eccentricity of the offset. The greater the speed of the crown, the larger is the arc of debulking and, ultimately, the resultant lumen size. A constant flow of saline solution is delivered by a roller pump that lubricates the device and helps to flush the debris. The Rotablator system high-speed rotational device uses calcium ablation to achieve larger lumens. It has been used for more than 20 years to treat challenging, calcified coronary artery disease. The diamond-coated burr is designed to preferentially engage calcium and modify lesion |
Surgery_Schwartz_6458 | Surgery_Schwartz | larger lumens. It has been used for more than 20 years to treat challenging, calcified coronary artery disease. The diamond-coated burr is designed to preferentially engage calcium and modify lesion compliance.Despite the promising early technical and clinical success, the midand long-term results have been disappointing due to high incidence of restenosis. A multicenter clinical registry of plaque atherectomy in patients with femoropopliteal occlusive disease showed potential clinical efficacy of this technology, as the 6and 12-month rates of survival free of target lesion revascularization were 90% and 80%, respectively.168 Impor-tantly, nearly three-quarters (73%) of patients treated with plaque excision modality did not require adjunctive endovas-cular therapy as infrainguinal stenting was necessary in only 6.3% of lesions. Results from the TALON registry support the role of plaque excision in selected patients with lower extremity arterial disease.Recent technologic advances have | Surgery_Schwartz. larger lumens. It has been used for more than 20 years to treat challenging, calcified coronary artery disease. The diamond-coated burr is designed to preferentially engage calcium and modify lesion compliance.Despite the promising early technical and clinical success, the midand long-term results have been disappointing due to high incidence of restenosis. A multicenter clinical registry of plaque atherectomy in patients with femoropopliteal occlusive disease showed potential clinical efficacy of this technology, as the 6and 12-month rates of survival free of target lesion revascularization were 90% and 80%, respectively.168 Impor-tantly, nearly three-quarters (73%) of patients treated with plaque excision modality did not require adjunctive endovas-cular therapy as infrainguinal stenting was necessary in only 6.3% of lesions. Results from the TALON registry support the role of plaque excision in selected patients with lower extremity arterial disease.Recent technologic advances have |
Surgery_Schwartz_6459 | Surgery_Schwartz | was necessary in only 6.3% of lesions. Results from the TALON registry support the role of plaque excision in selected patients with lower extremity arterial disease.Recent technologic advances have made it possible to increase the spectrum of treatable peripheral arterial lesions with high acute procedure success rates. Recently presented data from multiple registries have shown some promising results in terms of short-term primary patency rates and freedom from unplanned major amputation.169 Randomized clinical trials, which may provide conclusions on the effectiveness of these procedures, are expected.Laser Atherectomy. Since laser atherectomy was reported in the 1960s, a variety of innovative approaches have been devel-oped trying to overcome the limitation of laser angioplasty. Recent developments in Excimer laser technology have led to increased optimism regarding the ability to safely deliver laser energy. Excimer laser atherectomy approved by the FDA for peripheral artery | Surgery_Schwartz. was necessary in only 6.3% of lesions. Results from the TALON registry support the role of plaque excision in selected patients with lower extremity arterial disease.Recent technologic advances have made it possible to increase the spectrum of treatable peripheral arterial lesions with high acute procedure success rates. Recently presented data from multiple registries have shown some promising results in terms of short-term primary patency rates and freedom from unplanned major amputation.169 Randomized clinical trials, which may provide conclusions on the effectiveness of these procedures, are expected.Laser Atherectomy. Since laser atherectomy was reported in the 1960s, a variety of innovative approaches have been devel-oped trying to overcome the limitation of laser angioplasty. Recent developments in Excimer laser technology have led to increased optimism regarding the ability to safely deliver laser energy. Excimer laser atherectomy approved by the FDA for peripheral artery |
Surgery_Schwartz_6460 | Surgery_Schwartz | developments in Excimer laser technology have led to increased optimism regarding the ability to safely deliver laser energy. Excimer laser atherectomy approved by the FDA for peripheral artery intervention employs precision laser energy control (shallow tissue penetration) and safer wavelengths (ultraviolet as opposed to the infrared spectra in older laser technology), which decrease perforation and thermal injury to the treated vessels.A laser atherectomy catheter, with diameters varying from 0.9 to 2.5 mm, is tracked over the guidewire to the desired tar-get. Once activated, the Excimer laser uses ultraviolet energy to ablate the lesion and create a nonthrombogenic arterial lumen. This lumen is further dilated by an angioplasty balloon. Because the Excimer laser can potentially reduce the rate of distal embo-lization by evaporating the lesion, it may be used as an adjunct tool for ostial lesions and lesions that can be traversed by a wire but not an angioplasty balloon | Surgery_Schwartz. developments in Excimer laser technology have led to increased optimism regarding the ability to safely deliver laser energy. Excimer laser atherectomy approved by the FDA for peripheral artery intervention employs precision laser energy control (shallow tissue penetration) and safer wavelengths (ultraviolet as opposed to the infrared spectra in older laser technology), which decrease perforation and thermal injury to the treated vessels.A laser atherectomy catheter, with diameters varying from 0.9 to 2.5 mm, is tracked over the guidewire to the desired tar-get. Once activated, the Excimer laser uses ultraviolet energy to ablate the lesion and create a nonthrombogenic arterial lumen. This lumen is further dilated by an angioplasty balloon. Because the Excimer laser can potentially reduce the rate of distal embo-lization by evaporating the lesion, it may be used as an adjunct tool for ostial lesions and lesions that can be traversed by a wire but not an angioplasty balloon |
Surgery_Schwartz_6461 | Surgery_Schwartz | reduce the rate of distal embo-lization by evaporating the lesion, it may be used as an adjunct tool for ostial lesions and lesions that can be traversed by a wire but not an angioplasty balloon catheter.Several studies regarding the use of Excimer laser atherectomy combined with balloon angioplasty on lower extremity occlusive disease have shown promising clinical outcomes.199,200 The Peripheral Excimer Laser Angioplasty (PELA) trial involved 318 patients with chronic SFA occlusion Brunicardi_Ch23_p0897-p0980.indd 96427/02/19 4:15 PM 965ARTERIAL DISEASECHAPTER 23and achieved a technical success rate of 83.2%, a 1-year pri-mary patency rate of 33.6%, and an assisted-primary patency rate of 65%.170 Steinkamp and colleagues treated 127 patients with long-segment popliteal artery occlusion using laser ather-ectomy followed by balloon angioplasty and reported a 3-year primary patency rate of 22%.171 A multicenter clinical trial, the Laser Angioplasty for Critical Limb Ischemia (LACI) | Surgery_Schwartz. reduce the rate of distal embo-lization by evaporating the lesion, it may be used as an adjunct tool for ostial lesions and lesions that can be traversed by a wire but not an angioplasty balloon catheter.Several studies regarding the use of Excimer laser atherectomy combined with balloon angioplasty on lower extremity occlusive disease have shown promising clinical outcomes.199,200 The Peripheral Excimer Laser Angioplasty (PELA) trial involved 318 patients with chronic SFA occlusion Brunicardi_Ch23_p0897-p0980.indd 96427/02/19 4:15 PM 965ARTERIAL DISEASECHAPTER 23and achieved a technical success rate of 83.2%, a 1-year pri-mary patency rate of 33.6%, and an assisted-primary patency rate of 65%.170 Steinkamp and colleagues treated 127 patients with long-segment popliteal artery occlusion using laser ather-ectomy followed by balloon angioplasty and reported a 3-year primary patency rate of 22%.171 A multicenter clinical trial, the Laser Angioplasty for Critical Limb Ischemia (LACI) |
Surgery_Schwartz_6462 | Surgery_Schwartz | using laser ather-ectomy followed by balloon angioplasty and reported a 3-year primary patency rate of 22%.171 A multicenter clinical trial, the Laser Angioplasty for Critical Limb Ischemia (LACI) trial, sup-ports the efficacy of this treatment modality in selected patients, with 6-month primary patency and clinical improvement rates of 33% and 89%, respectively.172 The technology and devices continue to evolve. With the TurboBooster and Turbo-Tandem technologies (Spectranetics Corporation, Colorado Springs, CO), the efficacy of plaque reduction was reported to be sig-nificantly improved in the CliRpath Excimer Laser System to Enlarge Lumen Openings (CELLO) study.173 The CELLO study was a single-arm, prospective registry trial conducted at 17 investigational sites in the United States to evaluate the safety and efficacy of a modified laser catheter designed for the endovascular treatment of peripheral artery disease affecting the SFA and proximal popliteal artery. Laser ablation | Surgery_Schwartz. using laser ather-ectomy followed by balloon angioplasty and reported a 3-year primary patency rate of 22%.171 A multicenter clinical trial, the Laser Angioplasty for Critical Limb Ischemia (LACI) trial, sup-ports the efficacy of this treatment modality in selected patients, with 6-month primary patency and clinical improvement rates of 33% and 89%, respectively.172 The technology and devices continue to evolve. With the TurboBooster and Turbo-Tandem technologies (Spectranetics Corporation, Colorado Springs, CO), the efficacy of plaque reduction was reported to be sig-nificantly improved in the CliRpath Excimer Laser System to Enlarge Lumen Openings (CELLO) study.173 The CELLO study was a single-arm, prospective registry trial conducted at 17 investigational sites in the United States to evaluate the safety and efficacy of a modified laser catheter designed for the endovascular treatment of peripheral artery disease affecting the SFA and proximal popliteal artery. Laser ablation |
Surgery_Schwartz_6463 | Surgery_Schwartz | to evaluate the safety and efficacy of a modified laser catheter designed for the endovascular treatment of peripheral artery disease affecting the SFA and proximal popliteal artery. Laser ablation reduced percent diameter stenosis from 77% to 21% after adjunctive therapy with balloon angioplasty or balloon angioplasty with stenting; 12.3% patients did not receive postlaser adjunctive therapy. Patency rates were 59% and 54% at 6 and 12 months, respectively. Target lesion revascularization was not required in 76.9% of CELLO participants within the 1-year follow-up.Complications of Endovascular InterventionsAngioplasty-Related Complications. Complications related to PTA vary widely and include dissection, rupture, emboliza-tion, pseudoaneurysms, restenosis, hematoma, and acute occlu-sion secondary to thrombosis, vasospasm, or intimal injury. Clark and associates analyzed the data from 205 patients in the SCVIR Transluminal Angioplasty and Revascularization (STAR) registry and reported a | Surgery_Schwartz. to evaluate the safety and efficacy of a modified laser catheter designed for the endovascular treatment of peripheral artery disease affecting the SFA and proximal popliteal artery. Laser ablation reduced percent diameter stenosis from 77% to 21% after adjunctive therapy with balloon angioplasty or balloon angioplasty with stenting; 12.3% patients did not receive postlaser adjunctive therapy. Patency rates were 59% and 54% at 6 and 12 months, respectively. Target lesion revascularization was not required in 76.9% of CELLO participants within the 1-year follow-up.Complications of Endovascular InterventionsAngioplasty-Related Complications. Complications related to PTA vary widely and include dissection, rupture, emboliza-tion, pseudoaneurysms, restenosis, hematoma, and acute occlu-sion secondary to thrombosis, vasospasm, or intimal injury. Clark and associates analyzed the data from 205 patients in the SCVIR Transluminal Angioplasty and Revascularization (STAR) registry and reported a |
Surgery_Schwartz_6464 | Surgery_Schwartz | to thrombosis, vasospasm, or intimal injury. Clark and associates analyzed the data from 205 patients in the SCVIR Transluminal Angioplasty and Revascularization (STAR) registry and reported a complication rate of 7.3% for patients undergoing femoropopliteal angioplasty.174 Minor complications accounted for 75% of the cases, including distal emboli (41.7%), puncture site hematomas (41.7%), contained vessel rupture (8.3%), and vagal reactions (8.3%). In another study, Axisa and colleagues reported an overall rate of significant complica-tions for patients undergoing PTA of the lower extremities of 4.2%, including retroperitoneal bleeding (0.2%), false aneurysm (0.2%), ALI (1.5%), and vessel perforation (1.7%).175Complications limiting the application of subintimal angioplasty are parallel to those of PTA. A study investigating the use of subintimal angioplasty in 65 patients with SFA occlu-sion found that complications developed in 15% of patients.176 These complications included | Surgery_Schwartz. to thrombosis, vasospasm, or intimal injury. Clark and associates analyzed the data from 205 patients in the SCVIR Transluminal Angioplasty and Revascularization (STAR) registry and reported a complication rate of 7.3% for patients undergoing femoropopliteal angioplasty.174 Minor complications accounted for 75% of the cases, including distal emboli (41.7%), puncture site hematomas (41.7%), contained vessel rupture (8.3%), and vagal reactions (8.3%). In another study, Axisa and colleagues reported an overall rate of significant complica-tions for patients undergoing PTA of the lower extremities of 4.2%, including retroperitoneal bleeding (0.2%), false aneurysm (0.2%), ALI (1.5%), and vessel perforation (1.7%).175Complications limiting the application of subintimal angioplasty are parallel to those of PTA. A study investigating the use of subintimal angioplasty in 65 patients with SFA occlu-sion found that complications developed in 15% of patients.176 These complications included |
Surgery_Schwartz_6465 | Surgery_Schwartz | to those of PTA. A study investigating the use of subintimal angioplasty in 65 patients with SFA occlu-sion found that complications developed in 15% of patients.176 These complications included significant stenosis (44%), SFA rupture (6%), distal embolization (3%), retroperitoneal hemor-rhage (1.5%), and pseudoaneurysm (1.5%). Additional compli-cations reported included perforation, thrombosis, dissection, and extensions beyond the planned reentry site.177 Importantly, damage to significant collateral vessels may occur in 1% to 1.5% of patients who undergo subintimal angioplasty. If a suc-cessful channel is not achieved in this situation, the patient may have a compromised distal circulation that necessitates dis-tal bypass. Cryoplasty is a modified form of angioplasty, and long-term results on lower extremity intervention are not yet available. Fava and associates treated 15 patients with femo-ropopliteal disease and had a 13% complication rate involving guidewire dissection and | Surgery_Schwartz. to those of PTA. A study investigating the use of subintimal angioplasty in 65 patients with SFA occlu-sion found that complications developed in 15% of patients.176 These complications included significant stenosis (44%), SFA rupture (6%), distal embolization (3%), retroperitoneal hemor-rhage (1.5%), and pseudoaneurysm (1.5%). Additional compli-cations reported included perforation, thrombosis, dissection, and extensions beyond the planned reentry site.177 Importantly, damage to significant collateral vessels may occur in 1% to 1.5% of patients who undergo subintimal angioplasty. If a suc-cessful channel is not achieved in this situation, the patient may have a compromised distal circulation that necessitates dis-tal bypass. Cryoplasty is a modified form of angioplasty, and long-term results on lower extremity intervention are not yet available. Fava and associates treated 15 patients with femo-ropopliteal disease and had a 13% complication rate involving guidewire dissection and |
Surgery_Schwartz_6466 | Surgery_Schwartz | results on lower extremity intervention are not yet available. Fava and associates treated 15 patients with femo-ropopliteal disease and had a 13% complication rate involving guidewire dissection and PTA-induced dissection of a tandem lesion remote to the cryoplasty zone.178Endoluminal Stent– and Stent Graft–Related Complica-tions. In addition to the aforementioned complications with angioplasty, endoluminal stent is associated with the risk of stent fraction and deformity. The adductor canal has nonlami-nar flow dynamics, especially with walking. The forces exerted on the SFA include torsion, compression, extension, and flex-ion. These forces exert significant stress on the SFA and stents. In addition, the lower extremity is subject to external trauma, which further increases the risk of stent deformity and fracture (Fig. 23-67). The SIROCCO study showed that stent fracture, although not associated with clinical symptoms, occurs in 18.2% of the procedures involving both drug-eluting | Surgery_Schwartz. results on lower extremity intervention are not yet available. Fava and associates treated 15 patients with femo-ropopliteal disease and had a 13% complication rate involving guidewire dissection and PTA-induced dissection of a tandem lesion remote to the cryoplasty zone.178Endoluminal Stent– and Stent Graft–Related Complica-tions. In addition to the aforementioned complications with angioplasty, endoluminal stent is associated with the risk of stent fraction and deformity. The adductor canal has nonlami-nar flow dynamics, especially with walking. The forces exerted on the SFA include torsion, compression, extension, and flex-ion. These forces exert significant stress on the SFA and stents. In addition, the lower extremity is subject to external trauma, which further increases the risk of stent deformity and fracture (Fig. 23-67). The SIROCCO study showed that stent fracture, although not associated with clinical symptoms, occurs in 18.2% of the procedures involving both drug-eluting |
Surgery_Schwartz_6467 | Surgery_Schwartz | stent deformity and fracture (Fig. 23-67). The SIROCCO study showed that stent fracture, although not associated with clinical symptoms, occurs in 18.2% of the procedures involving both drug-eluting stents and control stents.163Stent grafts may present the additional complication of covering important collaterals, which results in compromised distal circulation. A prospective study evaluating Hemo-bahn stent grafts in the treatment of femoropopliteal arterial Figure 23-67. Due to various geometric forces, including torsion, compression, extension, and flexion, exerted on the superficial fem-oral artery (SFA), stent fracture (arrows) is a known complication following SFA stent placement.Brunicardi_Ch23_p0897-p0980.indd 96527/02/19 4:15 PM 966SPECIFIC CONSIDERATIONSPART IIocclusions demonstrated a 23% immediate complication rate including distal embolization (7.7%), groin hematoma (13.5%), and arteriovenous fistula (1.9%).179Atherectomy-Related Complications. Overall complication | Surgery_Schwartz. stent deformity and fracture (Fig. 23-67). The SIROCCO study showed that stent fracture, although not associated with clinical symptoms, occurs in 18.2% of the procedures involving both drug-eluting stents and control stents.163Stent grafts may present the additional complication of covering important collaterals, which results in compromised distal circulation. A prospective study evaluating Hemo-bahn stent grafts in the treatment of femoropopliteal arterial Figure 23-67. Due to various geometric forces, including torsion, compression, extension, and flexion, exerted on the superficial fem-oral artery (SFA), stent fracture (arrows) is a known complication following SFA stent placement.Brunicardi_Ch23_p0897-p0980.indd 96527/02/19 4:15 PM 966SPECIFIC CONSIDERATIONSPART IIocclusions demonstrated a 23% immediate complication rate including distal embolization (7.7%), groin hematoma (13.5%), and arteriovenous fistula (1.9%).179Atherectomy-Related Complications. Overall complication |
Surgery_Schwartz_6468 | Surgery_Schwartz | a 23% immediate complication rate including distal embolization (7.7%), groin hematoma (13.5%), and arteriovenous fistula (1.9%).179Atherectomy-Related Complications. Overall complication rates associated with atherectomy range from 15.4% to 42.8%, including spasm, thrombosis, dissection, perforation, distal emboli, no reflow, and hematoma.180,181 Jahnke and associates conducted a prospective study evaluating high-speed rotational atherectomy in 15 patients with infrapopliteal occlusive disease. They yielded a 94% technical success rate, but success was complicated by vessel rupture (5%), distal embolization (5%), and arterial spasm (5%).179 Although Excimer laser atherectomy reduces embolic events by evaporating the lesion, embolization still remains a problematic complication. Studies show that dis-tal embolic events occur in 3% to 4% of procedures and perfora-tion occurs in 2.2% to 4.3% of cases.170,171 Other complications associated with laser atherectomy therapy include acute | Surgery_Schwartz. a 23% immediate complication rate including distal embolization (7.7%), groin hematoma (13.5%), and arteriovenous fistula (1.9%).179Atherectomy-Related Complications. Overall complication rates associated with atherectomy range from 15.4% to 42.8%, including spasm, thrombosis, dissection, perforation, distal emboli, no reflow, and hematoma.180,181 Jahnke and associates conducted a prospective study evaluating high-speed rotational atherectomy in 15 patients with infrapopliteal occlusive disease. They yielded a 94% technical success rate, but success was complicated by vessel rupture (5%), distal embolization (5%), and arterial spasm (5%).179 Although Excimer laser atherectomy reduces embolic events by evaporating the lesion, embolization still remains a problematic complication. Studies show that dis-tal embolic events occur in 3% to 4% of procedures and perfora-tion occurs in 2.2% to 4.3% of cases.170,171 Other complications associated with laser atherectomy therapy include acute |
Surgery_Schwartz_6469 | Surgery_Schwartz | show that dis-tal embolic events occur in 3% to 4% of procedures and perfora-tion occurs in 2.2% to 4.3% of cases.170,171 Other complications associated with laser atherectomy therapy include acute throm-bosis, vasospasm, direct vessel injury, and dissection.170,171Surgical Treatment for Chronic Limb Ischemia due to Femoropopliteal DiseaseEndarterectomy. Endarterectomy has a limited, albeit impor-tant role in lower extremity occlusive disease. It is most fre-quently used when there is disease in the CFA or involving the PFA. In this procedure, the surgeon opens the diseased segment longitudinally and develops a cleavage plane within the media that is developed proximally and distally. This permits the inner layer containing the atheroma to be excised. Great care must be taken at the distal end of the endarterectomy to either ensure a smooth transition or tack down the distal endpoint to prevent the flow from elevating a potentially occlusive atheromatous flap. Currently, there is | Surgery_Schwartz. show that dis-tal embolic events occur in 3% to 4% of procedures and perfora-tion occurs in 2.2% to 4.3% of cases.170,171 Other complications associated with laser atherectomy therapy include acute throm-bosis, vasospasm, direct vessel injury, and dissection.170,171Surgical Treatment for Chronic Limb Ischemia due to Femoropopliteal DiseaseEndarterectomy. Endarterectomy has a limited, albeit impor-tant role in lower extremity occlusive disease. It is most fre-quently used when there is disease in the CFA or involving the PFA. In this procedure, the surgeon opens the diseased segment longitudinally and develops a cleavage plane within the media that is developed proximally and distally. This permits the inner layer containing the atheroma to be excised. Great care must be taken at the distal end of the endarterectomy to either ensure a smooth transition or tack down the distal endpoint to prevent the flow from elevating a potentially occlusive atheromatous flap. Currently, there is |
Surgery_Schwartz_6470 | Surgery_Schwartz | end of the endarterectomy to either ensure a smooth transition or tack down the distal endpoint to prevent the flow from elevating a potentially occlusive atheromatous flap. Currently, there is essentially no role for long open endar-terectomy in the treatment of SFA stenoses or occlusions. The high incidence of restenosis is what limits utility of endarterec-tomy in this location. Short-segment stenoses are more appro-priately treated with balloon angioplasty. Endarterectomy using a catheter-based approach (e.g., Moll endarterectomy device) supplemented with stent grafting or stenting across the endpoint of the endarterectomy is currently being reevaluated; however, no long-term data are available.Bypass Grafting. Bypass grafting remains the primary inter-vention for lower extremity occlusive disease. The type of bypass and the type of conduit are important variables to con-sider. Patients with occlusive disease limited to the SFA, who have at least 4 cm (ideally 10 cm) of normal | Surgery_Schwartz. end of the endarterectomy to either ensure a smooth transition or tack down the distal endpoint to prevent the flow from elevating a potentially occlusive atheromatous flap. Currently, there is essentially no role for long open endar-terectomy in the treatment of SFA stenoses or occlusions. The high incidence of restenosis is what limits utility of endarterec-tomy in this location. Short-segment stenoses are more appro-priately treated with balloon angioplasty. Endarterectomy using a catheter-based approach (e.g., Moll endarterectomy device) supplemented with stent grafting or stenting across the endpoint of the endarterectomy is currently being reevaluated; however, no long-term data are available.Bypass Grafting. Bypass grafting remains the primary inter-vention for lower extremity occlusive disease. The type of bypass and the type of conduit are important variables to con-sider. Patients with occlusive disease limited to the SFA, who have at least 4 cm (ideally 10 cm) of normal |
Surgery_Schwartz_6471 | Surgery_Schwartz | disease. The type of bypass and the type of conduit are important variables to con-sider. Patients with occlusive disease limited to the SFA, who have at least 4 cm (ideally 10 cm) of normal popliteal artery reconstituted above the knee joint, and with at least one continu-ous vessel to the foot can be treated with an above-knee femo-ropopliteal bypass graft. Despite the fact that in this above-knee location, the differential patencies between prosthetic (PTFE) and vein graft are comparable, undoubtedly, it remains ideal to use a saphenous vein as the bypass conduit if possible. Saving the vein for future coronary artery bypass or distal leg bypass grafting has been shown to be a flawed argument. One must also consider that the consequences to the vascular outflow after a thrombosed prosthetic are worse than after a thrombosed vein graft.When the disease extends to involve the popliteal artery or the tibial vessels, the surgeon must select an appropriate out-flow vessel to perform a | Surgery_Schwartz. disease. The type of bypass and the type of conduit are important variables to con-sider. Patients with occlusive disease limited to the SFA, who have at least 4 cm (ideally 10 cm) of normal popliteal artery reconstituted above the knee joint, and with at least one continu-ous vessel to the foot can be treated with an above-knee femo-ropopliteal bypass graft. Despite the fact that in this above-knee location, the differential patencies between prosthetic (PTFE) and vein graft are comparable, undoubtedly, it remains ideal to use a saphenous vein as the bypass conduit if possible. Saving the vein for future coronary artery bypass or distal leg bypass grafting has been shown to be a flawed argument. One must also consider that the consequences to the vascular outflow after a thrombosed prosthetic are worse than after a thrombosed vein graft.When the disease extends to involve the popliteal artery or the tibial vessels, the surgeon must select an appropriate out-flow vessel to perform a |
Surgery_Schwartz_6472 | Surgery_Schwartz | are worse than after a thrombosed vein graft.When the disease extends to involve the popliteal artery or the tibial vessels, the surgeon must select an appropriate out-flow vessel to perform a bypass. Suitable outflow vessels are defined as uninterrupted flow channels beyond the anastomosis into the foot. Listed in order of descending preference, they are as follows: above-knee popliteal artery, below-knee popli-teal artery, posterior tibial artery, anterior tibial artery, and peroneal artery. In patients with diabetes, it is frequently the peroneal artery that is spared. Although it has no direct flow into the foot, collateralization to the posterior tibial and anterior tibial arteries makes it an appropriate outflow vessel. There is no objective evidence to preferentially select tibial over peroneal arteries if they are vessels of equal caliber and quality. The dor-salis pedis, which is the continuation of the anterior tibial in the foot, is frequently spared from atherosclerotic | Surgery_Schwartz. are worse than after a thrombosed vein graft.When the disease extends to involve the popliteal artery or the tibial vessels, the surgeon must select an appropriate out-flow vessel to perform a bypass. Suitable outflow vessels are defined as uninterrupted flow channels beyond the anastomosis into the foot. Listed in order of descending preference, they are as follows: above-knee popliteal artery, below-knee popli-teal artery, posterior tibial artery, anterior tibial artery, and peroneal artery. In patients with diabetes, it is frequently the peroneal artery that is spared. Although it has no direct flow into the foot, collateralization to the posterior tibial and anterior tibial arteries makes it an appropriate outflow vessel. There is no objective evidence to preferentially select tibial over peroneal arteries if they are vessels of equal caliber and quality. The dor-salis pedis, which is the continuation of the anterior tibial in the foot, is frequently spared from atherosclerotic |
Surgery_Schwartz_6473 | Surgery_Schwartz | over peroneal arteries if they are vessels of equal caliber and quality. The dor-salis pedis, which is the continuation of the anterior tibial in the foot, is frequently spared from atherosclerotic disease and can be used as a target for distal bypasses. Patency is affected by the length of the bypass (longer bypasses have reduced patency), quality of the recipient artery, extent of runoff to the foot, and quality of the conduit (saphenous vein/graft). Five-year assisted patency rate for infrapopliteal venous bypasses is 60%. Venous conduits have also been shown to be suitable for bypasses to plantar arteries. In this location, venous conduits have a 3-year limb salvage rate of 84% and a 3-year secondary patency rate of 74%.1 A meta-analysis suggests unsatisfactory results when PTFE-coated grafts are used to bypass to infrapopliteal arteries. In this location, prosthetic grafts have a 5-year primary patency rate of 30.5%.182 Additionally, due to distal embolization and compromise of | Surgery_Schwartz. over peroneal arteries if they are vessels of equal caliber and quality. The dor-salis pedis, which is the continuation of the anterior tibial in the foot, is frequently spared from atherosclerotic disease and can be used as a target for distal bypasses. Patency is affected by the length of the bypass (longer bypasses have reduced patency), quality of the recipient artery, extent of runoff to the foot, and quality of the conduit (saphenous vein/graft). Five-year assisted patency rate for infrapopliteal venous bypasses is 60%. Venous conduits have also been shown to be suitable for bypasses to plantar arteries. In this location, venous conduits have a 3-year limb salvage rate of 84% and a 3-year secondary patency rate of 74%.1 A meta-analysis suggests unsatisfactory results when PTFE-coated grafts are used to bypass to infrapopliteal arteries. In this location, prosthetic grafts have a 5-year primary patency rate of 30.5%.182 Additionally, due to distal embolization and compromise of |
Surgery_Schwartz_6474 | Surgery_Schwartz | grafts are used to bypass to infrapopliteal arteries. In this location, prosthetic grafts have a 5-year primary patency rate of 30.5%.182 Additionally, due to distal embolization and compromise of outflow vessels, prosthetic graft occlusion may have more severe consequences than vein graft occlusion.Two techniques are used for distal bypass grafting: reversed saphenous vein grafting and in situ saphenous vein grafting. There is no difference in outcomes (patency or limb salvage) between these techniques. In the former, the vein is excised in its entirety from the leg using open or endoscopic vein harvest, reversed to render the valves nonfunctional, and tunneled from the CFA inflow to the distal target vessels. End-to-side anastomoses are then created.Several adjunctive techniques have been used to try to improve the patency of bypass grafts to tibial arteries. Cre-ation of an arteriovenous fistula at the distal anastomosis is one option, but it has not been shown to improve | Surgery_Schwartz. grafts are used to bypass to infrapopliteal arteries. In this location, prosthetic grafts have a 5-year primary patency rate of 30.5%.182 Additionally, due to distal embolization and compromise of outflow vessels, prosthetic graft occlusion may have more severe consequences than vein graft occlusion.Two techniques are used for distal bypass grafting: reversed saphenous vein grafting and in situ saphenous vein grafting. There is no difference in outcomes (patency or limb salvage) between these techniques. In the former, the vein is excised in its entirety from the leg using open or endoscopic vein harvest, reversed to render the valves nonfunctional, and tunneled from the CFA inflow to the distal target vessels. End-to-side anastomoses are then created.Several adjunctive techniques have been used to try to improve the patency of bypass grafts to tibial arteries. Cre-ation of an arteriovenous fistula at the distal anastomosis is one option, but it has not been shown to improve |
Surgery_Schwartz_6475 | Surgery_Schwartz | have been used to try to improve the patency of bypass grafts to tibial arteries. Cre-ation of an arteriovenous fistula at the distal anastomosis is one option, but it has not been shown to improve patency.183 Another method involves creating varying configurations of vein cuffs or patches at the distal anastomosis in an attempt to streamline the flow and to reduce the likelihood of neointimal hyperplasia. Results with this approach are more promising, especially when done to improve patency of a below-the-knee prosthetic; how-ever, there are no definitive comparative trials that support the superiority of one configuration over another.Amputation. Primary amputation is defined as an amputation that is performed without a prior attempt at surgical or endovas-cular revascularization. It is rarely necessary in patients who, as a result of neglect, present with class III ALI. Primary ampu-tation may play a role in patients with critical limb ischemia who are deemed nonambulatory because | Surgery_Schwartz. have been used to try to improve the patency of bypass grafts to tibial arteries. Cre-ation of an arteriovenous fistula at the distal anastomosis is one option, but it has not been shown to improve patency.183 Another method involves creating varying configurations of vein cuffs or patches at the distal anastomosis in an attempt to streamline the flow and to reduce the likelihood of neointimal hyperplasia. Results with this approach are more promising, especially when done to improve patency of a below-the-knee prosthetic; how-ever, there are no definitive comparative trials that support the superiority of one configuration over another.Amputation. Primary amputation is defined as an amputation that is performed without a prior attempt at surgical or endovas-cular revascularization. It is rarely necessary in patients who, as a result of neglect, present with class III ALI. Primary ampu-tation may play a role in patients with critical limb ischemia who are deemed nonambulatory because |
Surgery_Schwartz_6476 | Surgery_Schwartz | rarely necessary in patients who, as a result of neglect, present with class III ALI. Primary ampu-tation may play a role in patients with critical limb ischemia who are deemed nonambulatory because of knee contractures, debilitating strokes, or dementia.Complications of Surgical ReconstructionVein Graft Stenoses. Fifteen percent of vein grafts will develop intrinsic stenoses within the first 18 months follow-ing implantation. Consequently, patients with vein grafts were entered into duplex surveillance protocols (scans every 3 months) to detect elevated (>300 cm/s) or abnormally low (<45 cm/s) graft velocities early. Stenoses greater than 50%, especially if associated with changes in ABI, should be repaired to prevent graft thrombosis. Repair usually entails patch angio-plasty or short-segment venous interposition, but PTA/stenting Brunicardi_Ch23_p0897-p0980.indd 96627/02/19 4:15 PM 967ARTERIAL DISEASECHAPTER 23is an option for short, focal lesions. Grafts with stenoses that are | Surgery_Schwartz. rarely necessary in patients who, as a result of neglect, present with class III ALI. Primary ampu-tation may play a role in patients with critical limb ischemia who are deemed nonambulatory because of knee contractures, debilitating strokes, or dementia.Complications of Surgical ReconstructionVein Graft Stenoses. Fifteen percent of vein grafts will develop intrinsic stenoses within the first 18 months follow-ing implantation. Consequently, patients with vein grafts were entered into duplex surveillance protocols (scans every 3 months) to detect elevated (>300 cm/s) or abnormally low (<45 cm/s) graft velocities early. Stenoses greater than 50%, especially if associated with changes in ABI, should be repaired to prevent graft thrombosis. Repair usually entails patch angio-plasty or short-segment venous interposition, but PTA/stenting Brunicardi_Ch23_p0897-p0980.indd 96627/02/19 4:15 PM 967ARTERIAL DISEASECHAPTER 23is an option for short, focal lesions. Grafts with stenoses that are |
Surgery_Schwartz_6477 | Surgery_Schwartz | venous interposition, but PTA/stenting Brunicardi_Ch23_p0897-p0980.indd 96627/02/19 4:15 PM 967ARTERIAL DISEASECHAPTER 23is an option for short, focal lesions. Grafts with stenoses that are identified and repaired prior to thrombosis have assisted-primary patency identical to primary patency, whereas a throm-bosed autogenous bypass has limited longevity resulting from ischemic injury to the vein wall. Secondary patency is mark-edly inferior to primary assisted patency. The recommenda-tion for routine duplex ultrasound surveillance of autogenous infrainguinal bypasses was recently brought into question by a randomized controlled trial that demonstrated no cost benefit or quality-of-life improvement in patients with femoropopliteal venous bypasses after 18 months.184 Many surgeons continue with programs of vein graft surveillance, as has been suggested in older trials, awaiting further confirmation of the findings from the more recent study. When intervening in a failing | Surgery_Schwartz. venous interposition, but PTA/stenting Brunicardi_Ch23_p0897-p0980.indd 96627/02/19 4:15 PM 967ARTERIAL DISEASECHAPTER 23is an option for short, focal lesions. Grafts with stenoses that are identified and repaired prior to thrombosis have assisted-primary patency identical to primary patency, whereas a throm-bosed autogenous bypass has limited longevity resulting from ischemic injury to the vein wall. Secondary patency is mark-edly inferior to primary assisted patency. The recommenda-tion for routine duplex ultrasound surveillance of autogenous infrainguinal bypasses was recently brought into question by a randomized controlled trial that demonstrated no cost benefit or quality-of-life improvement in patients with femoropopliteal venous bypasses after 18 months.184 Many surgeons continue with programs of vein graft surveillance, as has been suggested in older trials, awaiting further confirmation of the findings from the more recent study. When intervening in a failing |
Surgery_Schwartz_6478 | Surgery_Schwartz | continue with programs of vein graft surveillance, as has been suggested in older trials, awaiting further confirmation of the findings from the more recent study. When intervening in a failing infraingui-nal bypass, the original indication for surgery is an important consideration. Limb salvage rates for occluded grafts are better if the indication for the original bypass was claudication rather than rest pain or tissue loss. An acutely occluded infrainguinal graft (≤30 postoperative days) has a 25% limb salvage rate.185Limb Swelling. Limb swelling is common following revascu-larization and usually returns to baseline within 2 to 3 months. The etiology is multifactorial with lymphatic interruption, inter-stitial edema, and disruption of venous drainage all contributing. Limb swelling tends to worsen with repeat revascularization (see Table 23-22).Wound Infection. Since the most common inflow vessel for distal bypass is the CFA, groin infection is common and occurs in 7% of cases.186 | Surgery_Schwartz. continue with programs of vein graft surveillance, as has been suggested in older trials, awaiting further confirmation of the findings from the more recent study. When intervening in a failing infraingui-nal bypass, the original indication for surgery is an important consideration. Limb salvage rates for occluded grafts are better if the indication for the original bypass was claudication rather than rest pain or tissue loss. An acutely occluded infrainguinal graft (≤30 postoperative days) has a 25% limb salvage rate.185Limb Swelling. Limb swelling is common following revascu-larization and usually returns to baseline within 2 to 3 months. The etiology is multifactorial with lymphatic interruption, inter-stitial edema, and disruption of venous drainage all contributing. Limb swelling tends to worsen with repeat revascularization (see Table 23-22).Wound Infection. Since the most common inflow vessel for distal bypass is the CFA, groin infection is common and occurs in 7% of cases.186 |
Surgery_Schwartz_6479 | Surgery_Schwartz | to worsen with repeat revascularization (see Table 23-22).Wound Infection. Since the most common inflow vessel for distal bypass is the CFA, groin infection is common and occurs in 7% of cases.186 When an autogenous conduit such as the saphenous vein is used, most infections can be managed with local wound care because the infection involves the subcutane-ous tissue or skin rather than infection of the actual vein. When a prosthetic graft has been used, management of graft infection is a major undertaking. Infection of a lower extremity prosthetic bypass graft is associated with a significant amputation rate because of the tendency for graft thrombosis and anastomotic disruption. Prosthetic graft infections cannot be eradicated with antibiotics and mandate graft excision and complex revascular-ization using a vein if available.Choice of Conduit for Infrainguinal Bypass GraftingAutogenous Vein. The autogenous vein is superior to pros-thetic conduits for all infrainguinal bypasses, | Surgery_Schwartz. to worsen with repeat revascularization (see Table 23-22).Wound Infection. Since the most common inflow vessel for distal bypass is the CFA, groin infection is common and occurs in 7% of cases.186 When an autogenous conduit such as the saphenous vein is used, most infections can be managed with local wound care because the infection involves the subcutane-ous tissue or skin rather than infection of the actual vein. When a prosthetic graft has been used, management of graft infection is a major undertaking. Infection of a lower extremity prosthetic bypass graft is associated with a significant amputation rate because of the tendency for graft thrombosis and anastomotic disruption. Prosthetic graft infections cannot be eradicated with antibiotics and mandate graft excision and complex revascular-ization using a vein if available.Choice of Conduit for Infrainguinal Bypass GraftingAutogenous Vein. The autogenous vein is superior to pros-thetic conduits for all infrainguinal bypasses, |
Surgery_Schwartz_6480 | Surgery_Schwartz | using a vein if available.Choice of Conduit for Infrainguinal Bypass GraftingAutogenous Vein. The autogenous vein is superior to pros-thetic conduits for all infrainguinal bypasses, even in the above-knee position. This preference is applicable not only for the initial bypass but also for reoperative cases. For long bypasses, the ipsilateral great saphenous vein, contralateral great saphe-nous vein, small saphenous vein, arm vein, and spliced vein are used in decreasing order of preference. If only a short segment of vein is missing, the SFA can be endarterectomized and the proximal anastomosis performed distally to decrease the length of the conduit and to avoid harvesting and splicing additional vein. When the great saphenous vein is not available and a rela-tively short bypass is necessary, the arm vein or small saphe-nous vein is effective. The small saphenous vein is of particular utility when a posterior approach is used. If a longer bypass with vein is necessary, the arm vein | Surgery_Schwartz. using a vein if available.Choice of Conduit for Infrainguinal Bypass GraftingAutogenous Vein. The autogenous vein is superior to pros-thetic conduits for all infrainguinal bypasses, even in the above-knee position. This preference is applicable not only for the initial bypass but also for reoperative cases. For long bypasses, the ipsilateral great saphenous vein, contralateral great saphe-nous vein, small saphenous vein, arm vein, and spliced vein are used in decreasing order of preference. If only a short segment of vein is missing, the SFA can be endarterectomized and the proximal anastomosis performed distally to decrease the length of the conduit and to avoid harvesting and splicing additional vein. When the great saphenous vein is not available and a rela-tively short bypass is necessary, the arm vein or small saphe-nous vein is effective. The small saphenous vein is of particular utility when a posterior approach is used. If a longer bypass with vein is necessary, the arm vein |
Surgery_Schwartz_6481 | Surgery_Schwartz | the arm vein or small saphe-nous vein is effective. The small saphenous vein is of particular utility when a posterior approach is used. If a longer bypass with vein is necessary, the arm vein is preferable because it is less awkward to harvest. Another conduit alternative is to har-vest the upper arm basilic, median cubital, and cephalic veins in continuity, while incising valves in the basilic segment and using the cephalic segment in reversed configuration to provide a relatively long, unspliced autogenous conduit.187Cryopreserved Grafts. Cryopreserved grafts are usually cadaveric arteries or veins that have been subjected to rate-controlled freezing with dimethyl sulfoxide (DMSO) and other cryopreservants. Cryopreserved vein grafts are more expensive than prosthetic grafts and are more prone to failure. The endo-thelial lining is lost as part of the freezing process, making these grafts prone to early thrombosis. Cryopreserved grafts are also prone to aneurysmal degeneration. | Surgery_Schwartz. the arm vein or small saphe-nous vein is effective. The small saphenous vein is of particular utility when a posterior approach is used. If a longer bypass with vein is necessary, the arm vein is preferable because it is less awkward to harvest. Another conduit alternative is to har-vest the upper arm basilic, median cubital, and cephalic veins in continuity, while incising valves in the basilic segment and using the cephalic segment in reversed configuration to provide a relatively long, unspliced autogenous conduit.187Cryopreserved Grafts. Cryopreserved grafts are usually cadaveric arteries or veins that have been subjected to rate-controlled freezing with dimethyl sulfoxide (DMSO) and other cryopreservants. Cryopreserved vein grafts are more expensive than prosthetic grafts and are more prone to failure. The endo-thelial lining is lost as part of the freezing process, making these grafts prone to early thrombosis. Cryopreserved grafts are also prone to aneurysmal degeneration. |
Surgery_Schwartz_6482 | Surgery_Schwartz | more prone to failure. The endo-thelial lining is lost as part of the freezing process, making these grafts prone to early thrombosis. Cryopreserved grafts are also prone to aneurysmal degeneration. Despite the fact that these grafts have not performed as well as prosthetic bypasses and autogenous vein bypasses in clinical practice, they can still play a role when revascularization is required following removal of infected prosthetic bypass grafts, especially when the autog-enous vein is unavailable to create a new bypass through clean tissue planes.Human Umbilical Vein. Human umbilical vein (HUV) is less commonly used than PTFE because it is thicker and more cum-bersome to handle and because of concerns about aneurysmal degeneration. HUV allografts are stabilized with glutaralde-hyde and do not have viable cells or antigenic reactivity. These grafts have poor handling characteristics and require extra care when suturing because of an outer Dacron mesh wrapping that is used to | Surgery_Schwartz. more prone to failure. The endo-thelial lining is lost as part of the freezing process, making these grafts prone to early thrombosis. Cryopreserved grafts are also prone to aneurysmal degeneration. Despite the fact that these grafts have not performed as well as prosthetic bypasses and autogenous vein bypasses in clinical practice, they can still play a role when revascularization is required following removal of infected prosthetic bypass grafts, especially when the autog-enous vein is unavailable to create a new bypass through clean tissue planes.Human Umbilical Vein. Human umbilical vein (HUV) is less commonly used than PTFE because it is thicker and more cum-bersome to handle and because of concerns about aneurysmal degeneration. HUV allografts are stabilized with glutaralde-hyde and do not have viable cells or antigenic reactivity. These grafts have poor handling characteristics and require extra care when suturing because of an outer Dacron mesh wrapping that is used to |
Surgery_Schwartz_6483 | Surgery_Schwartz | and do not have viable cells or antigenic reactivity. These grafts have poor handling characteristics and require extra care when suturing because of an outer Dacron mesh wrapping that is used to decrease aneurysmal degeneration. Dardik and col-leagues have reported favorable results after using HUV and an adjunctive distal arteriovenous fistula.188 One trial compar-ing HUV with PTFE and saphenous vein showed that HUV was better than PTFE but worse than saphenous vein in terms of 5-year patency in the above-knee location.189 In a system-atic review, HUV appears to perform better than cryopre-served veins in terms of 1-year graft patency in infrainguinal revascularization.190Prosthetic Conduits and Adjunctive Modifications. If a vein is truly unavailable, PTFE or Dacron is the best option for above-knee bypass. The addition of rings to PTFE did not con-fer benefit in a single prospective, randomized clinical trial.191 For infrageniculate prosthetic bypasses, use of a vein patch, cuff, | Surgery_Schwartz. and do not have viable cells or antigenic reactivity. These grafts have poor handling characteristics and require extra care when suturing because of an outer Dacron mesh wrapping that is used to decrease aneurysmal degeneration. Dardik and col-leagues have reported favorable results after using HUV and an adjunctive distal arteriovenous fistula.188 One trial compar-ing HUV with PTFE and saphenous vein showed that HUV was better than PTFE but worse than saphenous vein in terms of 5-year patency in the above-knee location.189 In a system-atic review, HUV appears to perform better than cryopre-served veins in terms of 1-year graft patency in infrainguinal revascularization.190Prosthetic Conduits and Adjunctive Modifications. If a vein is truly unavailable, PTFE or Dacron is the best option for above-knee bypass. The addition of rings to PTFE did not con-fer benefit in a single prospective, randomized clinical trial.191 For infrageniculate prosthetic bypasses, use of a vein patch, cuff, |
Surgery_Schwartz_6484 | Surgery_Schwartz | for above-knee bypass. The addition of rings to PTFE did not con-fer benefit in a single prospective, randomized clinical trial.191 For infrageniculate prosthetic bypasses, use of a vein patch, cuff, or other venous anastomotic modification can improve patency (52% patency at 2 years for PTFE with vein cuff vs. 29% for PTFE with no cuff) and also improve limb salvage (84% vs. 62%).192Although prosthetic grafts are quickly available, easy to handle, and do not require extensive dissection to harvest, their propensity to undergo thrombosis and develop neointimal hyperplasia makes them a less favorable alternative when com-pared to vein. In a recent review of vein and prosthetic above-knee femoropopliteal bypasses, the 5-year primary patency rates were reported to be 74% and 39%, respectively.193 Outcomes were even worse for below-knee prosthetic bypasses. Unfortu-nately, the use of autologous venous conduits is not possible in as many as 30% of patients. The great saphenous vein may be | Surgery_Schwartz. for above-knee bypass. The addition of rings to PTFE did not con-fer benefit in a single prospective, randomized clinical trial.191 For infrageniculate prosthetic bypasses, use of a vein patch, cuff, or other venous anastomotic modification can improve patency (52% patency at 2 years for PTFE with vein cuff vs. 29% for PTFE with no cuff) and also improve limb salvage (84% vs. 62%).192Although prosthetic grafts are quickly available, easy to handle, and do not require extensive dissection to harvest, their propensity to undergo thrombosis and develop neointimal hyperplasia makes them a less favorable alternative when com-pared to vein. In a recent review of vein and prosthetic above-knee femoropopliteal bypasses, the 5-year primary patency rates were reported to be 74% and 39%, respectively.193 Outcomes were even worse for below-knee prosthetic bypasses. Unfortu-nately, the use of autologous venous conduits is not possible in as many as 30% of patients. The great saphenous vein may be |
Surgery_Schwartz_6485 | Surgery_Schwartz | Outcomes were even worse for below-knee prosthetic bypasses. Unfortu-nately, the use of autologous venous conduits is not possible in as many as 30% of patients. The great saphenous vein may be unsuitable because of small size and poor quality or unavailable due to prior harvest.Methods to improve prosthetic graft performance have consisted of altering the geometry at the distal anastomosis to get the benefit obtained with vein cuffs (Distaflo; Bard Peripheral Vascular, Tempe, AZ) and covalently bonding agents onto the luminal surface with anticoagulant, anti-inflammatory, and anti-proliferative characteristics (Propaten; Gore, Flagstaff, AZ). One randomized trial that compared precuffed PTFE versus PTFE with a vein cuff enrolled 104 patients at 10 centers. Of 89 patients, 47 were randomized to precuffed PTFE bypasses and 44 were randomized to bypasses with a vein cuff.194 At 1 and Brunicardi_Ch23_p0897-p0980.indd 96727/02/19 4:15 PM 968SPECIFIC CONSIDERATIONSPART II2 years, | Surgery_Schwartz. Outcomes were even worse for below-knee prosthetic bypasses. Unfortu-nately, the use of autologous venous conduits is not possible in as many as 30% of patients. The great saphenous vein may be unsuitable because of small size and poor quality or unavailable due to prior harvest.Methods to improve prosthetic graft performance have consisted of altering the geometry at the distal anastomosis to get the benefit obtained with vein cuffs (Distaflo; Bard Peripheral Vascular, Tempe, AZ) and covalently bonding agents onto the luminal surface with anticoagulant, anti-inflammatory, and anti-proliferative characteristics (Propaten; Gore, Flagstaff, AZ). One randomized trial that compared precuffed PTFE versus PTFE with a vein cuff enrolled 104 patients at 10 centers. Of 89 patients, 47 were randomized to precuffed PTFE bypasses and 44 were randomized to bypasses with a vein cuff.194 At 1 and Brunicardi_Ch23_p0897-p0980.indd 96727/02/19 4:15 PM 968SPECIFIC CONSIDERATIONSPART II2 years, |
Surgery_Schwartz_6486 | Surgery_Schwartz | to precuffed PTFE bypasses and 44 were randomized to bypasses with a vein cuff.194 At 1 and Brunicardi_Ch23_p0897-p0980.indd 96727/02/19 4:15 PM 968SPECIFIC CONSIDERATIONSPART II2 years, primary patency rates were 52% and 49% in the pre-cuffed group and 62% and 44% in the vein cuffed group, respec-tively. At 1 and 2 years, the limb salvage rates were 72% and 65% in the precuffed group and 75% and 62% in the vein cuffed group, respectively. Although numbers are small and follow-up short, the midterm analysis revealed that Distaflo precuffed grafts and PTFE grafts with vein cuff had similar results. The authors concluded that a precuffed graft was a reasonable alternative for infragenicular reconstruction in the absence of saphenous vein.194 Other authors have been less optimistic and question whether there is any benefit derived from geometri-cally altering prosthetic conduits.195Another approach for improving outcomes when using prosthetic for bypass grafts involves bonding | Surgery_Schwartz. to precuffed PTFE bypasses and 44 were randomized to bypasses with a vein cuff.194 At 1 and Brunicardi_Ch23_p0897-p0980.indd 96727/02/19 4:15 PM 968SPECIFIC CONSIDERATIONSPART II2 years, primary patency rates were 52% and 49% in the pre-cuffed group and 62% and 44% in the vein cuffed group, respec-tively. At 1 and 2 years, the limb salvage rates were 72% and 65% in the precuffed group and 75% and 62% in the vein cuffed group, respectively. Although numbers are small and follow-up short, the midterm analysis revealed that Distaflo precuffed grafts and PTFE grafts with vein cuff had similar results. The authors concluded that a precuffed graft was a reasonable alternative for infragenicular reconstruction in the absence of saphenous vein.194 Other authors have been less optimistic and question whether there is any benefit derived from geometri-cally altering prosthetic conduits.195Another approach for improving outcomes when using prosthetic for bypass grafts involves bonding |
Surgery_Schwartz_6487 | Surgery_Schwartz | and question whether there is any benefit derived from geometri-cally altering prosthetic conduits.195Another approach for improving outcomes when using prosthetic for bypass grafts involves bonding anticoagulants to the conduit. The Gore Propaten graft has heparin bonded onto the luminal surface of the PTFE graft using Carmeda BioActive Surface (CBAS) technology, which immobilizes the heparin molecule with a single covalent bond that does not alter its anti-coagulant properties.196 The heparin binding does not alter the microstructure and handling characteristics of the PTFE. A pro-spective, randomized trial by Devine and colleagues suggested that heparin-bonded Dacron or PTFE was superior to plain PTFE for above-knee popliteal bypasses. The 3-year primary patency rate for the heparin-bonded grafts was 55% compared with 42% for PTFE (P <0.044). Both of these patency rates are inferior to great saphenous vein grafts; however, if the improved results with heparin bonding continue to be | Surgery_Schwartz. and question whether there is any benefit derived from geometri-cally altering prosthetic conduits.195Another approach for improving outcomes when using prosthetic for bypass grafts involves bonding anticoagulants to the conduit. The Gore Propaten graft has heparin bonded onto the luminal surface of the PTFE graft using Carmeda BioActive Surface (CBAS) technology, which immobilizes the heparin molecule with a single covalent bond that does not alter its anti-coagulant properties.196 The heparin binding does not alter the microstructure and handling characteristics of the PTFE. A pro-spective, randomized trial by Devine and colleagues suggested that heparin-bonded Dacron or PTFE was superior to plain PTFE for above-knee popliteal bypasses. The 3-year primary patency rate for the heparin-bonded grafts was 55% compared with 42% for PTFE (P <0.044). Both of these patency rates are inferior to great saphenous vein grafts; however, if the improved results with heparin bonding continue to be |
Surgery_Schwartz_6488 | Surgery_Schwartz | grafts was 55% compared with 42% for PTFE (P <0.044). Both of these patency rates are inferior to great saphenous vein grafts; however, if the improved results with heparin bonding continue to be substantiated, then heparin-bonded prosthetic grafts will become the preferred con-duit for above-knee bypass in the absence of suitable vein.197 A recent review of available studies with this graft showed an 80% 1-year patency rate for below-knee bypasses.198 Randomized controlled clinical trials with more patients and longer follow-up are necessary to validate whether the Propaten vascular graft is superior to other prosthetics and whether it is comparable to autogenous vein for below-knee interventions.Clinical Results of Surgical and Endovascular Interventions for Femoropopliteal Occlusive DiseaseBalloon angioplasty of the femoropopliteal vessels has not enjoyed the degree of success seen with iliac angioplasty. Patency in this region is dependent on whether the patient pres-ents with | Surgery_Schwartz. grafts was 55% compared with 42% for PTFE (P <0.044). Both of these patency rates are inferior to great saphenous vein grafts; however, if the improved results with heparin bonding continue to be substantiated, then heparin-bonded prosthetic grafts will become the preferred con-duit for above-knee bypass in the absence of suitable vein.197 A recent review of available studies with this graft showed an 80% 1-year patency rate for below-knee bypasses.198 Randomized controlled clinical trials with more patients and longer follow-up are necessary to validate whether the Propaten vascular graft is superior to other prosthetics and whether it is comparable to autogenous vein for below-knee interventions.Clinical Results of Surgical and Endovascular Interventions for Femoropopliteal Occlusive DiseaseBalloon angioplasty of the femoropopliteal vessels has not enjoyed the degree of success seen with iliac angioplasty. Patency in this region is dependent on whether the patient pres-ents with |
Surgery_Schwartz_6489 | Surgery_Schwartz | DiseaseBalloon angioplasty of the femoropopliteal vessels has not enjoyed the degree of success seen with iliac angioplasty. Patency in this region is dependent on whether the patient pres-ents with claudication versus limb-threatening ischemia, the sta-tus of the distal runoff vessels, and lesion morphology. Initial technical success for femoropopliteal angioplasty is seen in 80% to 90% of cases, with failure to cross a lesion occurring in 7% of stenoses and 18% of occlusive lesions. Studies have shown that PTA of the femoropopliteal segment achieved a greater than 90% technical success rate and had a 38% to 58% 5-year pri-mary patency rate.152,199 PTA of lesions longer than 7 to 10 cm results in compromised patency, whereas PTA of shorter lesions (<3 cm) gives fairly good results. Lofberg and colleagues per-formed 127 femoropopliteal PTA procedures and reported a primary patency rate at 5-year follow-up of 12% in limbs with occlusion longer than 5 cm versus 32% in limbs with | Surgery_Schwartz. DiseaseBalloon angioplasty of the femoropopliteal vessels has not enjoyed the degree of success seen with iliac angioplasty. Patency in this region is dependent on whether the patient pres-ents with claudication versus limb-threatening ischemia, the sta-tus of the distal runoff vessels, and lesion morphology. Initial technical success for femoropopliteal angioplasty is seen in 80% to 90% of cases, with failure to cross a lesion occurring in 7% of stenoses and 18% of occlusive lesions. Studies have shown that PTA of the femoropopliteal segment achieved a greater than 90% technical success rate and had a 38% to 58% 5-year pri-mary patency rate.152,199 PTA of lesions longer than 7 to 10 cm results in compromised patency, whereas PTA of shorter lesions (<3 cm) gives fairly good results. Lofberg and colleagues per-formed 127 femoropopliteal PTA procedures and reported a primary patency rate at 5-year follow-up of 12% in limbs with occlusion longer than 5 cm versus 32% in limbs with |
Surgery_Schwartz_6490 | Surgery_Schwartz | Lofberg and colleagues per-formed 127 femoropopliteal PTA procedures and reported a primary patency rate at 5-year follow-up of 12% in limbs with occlusion longer than 5 cm versus 32% in limbs with occlusion less than 5 cm in length.151 Occlusive lesions have much worse initial technical success rates than stenotic lesions. Concentric lesions respond better to PTA than eccentric lesions, and heavy calcifications have a negative impact on success rates. Distal runoff is another powerful predictor of long-term success.Johnston analyzed 254 consecutive patients who under-went femoropopliteal PTA and reported a 5-year patency rate of 53% for stenotic lesions and 36% for occlusive lesions in patients with good runoff versus a 5-year patency rate of 31% for stenotic lesions and 16% for occlusive lesions in patients with poor runoff.149 A meta-analysis by Hunink and colleagues showed that adjusted 5-year primary patencies after angioplasty of femoropopliteal lesions varied from 12% to 68%, | Surgery_Schwartz. Lofberg and colleagues per-formed 127 femoropopliteal PTA procedures and reported a primary patency rate at 5-year follow-up of 12% in limbs with occlusion longer than 5 cm versus 32% in limbs with occlusion less than 5 cm in length.151 Occlusive lesions have much worse initial technical success rates than stenotic lesions. Concentric lesions respond better to PTA than eccentric lesions, and heavy calcifications have a negative impact on success rates. Distal runoff is another powerful predictor of long-term success.Johnston analyzed 254 consecutive patients who under-went femoropopliteal PTA and reported a 5-year patency rate of 53% for stenotic lesions and 36% for occlusive lesions in patients with good runoff versus a 5-year patency rate of 31% for stenotic lesions and 16% for occlusive lesions in patients with poor runoff.149 A meta-analysis by Hunink and colleagues showed that adjusted 5-year primary patencies after angioplasty of femoropopliteal lesions varied from 12% to 68%, |
Surgery_Schwartz_6491 | Surgery_Schwartz | lesions in patients with poor runoff.149 A meta-analysis by Hunink and colleagues showed that adjusted 5-year primary patencies after angioplasty of femoropopliteal lesions varied from 12% to 68%, with the best results occurring in patients with claudication and stenotic lesions.152 Although the initial technical success is better for stenoses than occlusions, long-term patency rates for stenoses and short occlusions have been variable, and there have been conflicting results regarding the efficacy of stent use. Early pub-lished series that examined efficacy of femoropopliteal artery stents showed patency rates that were comparable to standalone PTA, with primary patency rates varying from 18% to 72% at 3 years.158 Patient selection and the anatomic character of the lesions may play important roles in the outcomes. Additionally, stent characteristics may contribute to the patency rate. Several recent clinical studies have demonstrated significant improve-ments in patency when the | Surgery_Schwartz. lesions in patients with poor runoff.149 A meta-analysis by Hunink and colleagues showed that adjusted 5-year primary patencies after angioplasty of femoropopliteal lesions varied from 12% to 68%, with the best results occurring in patients with claudication and stenotic lesions.152 Although the initial technical success is better for stenoses than occlusions, long-term patency rates for stenoses and short occlusions have been variable, and there have been conflicting results regarding the efficacy of stent use. Early pub-lished series that examined efficacy of femoropopliteal artery stents showed patency rates that were comparable to standalone PTA, with primary patency rates varying from 18% to 72% at 3 years.158 Patient selection and the anatomic character of the lesions may play important roles in the outcomes. Additionally, stent characteristics may contribute to the patency rate. Several recent clinical studies have demonstrated significant improve-ments in patency when the |
Surgery_Schwartz_6492 | Surgery_Schwartz | roles in the outcomes. Additionally, stent characteristics may contribute to the patency rate. Several recent clinical studies have demonstrated significant improve-ments in patency when the newer generations of nitinol stents are used to treat SFA lesions.160,200Mewissen treated 137 lower limbs in 122 patients with CLI, secondary to TASC A (n = 12) or TASC B or C (n = 125) lesions in the SFA. Patients were treated with Cordis SMART self-expanding nitinol stents. Binary restenosis (>50%) was measured by standard duplex velocity criteria at various postint-ervention intervals. Primary stent patency, defined as absence of binary restenosis in this study, was calculated by life-table methods from the time of intervention. The mean lesion length was 12.2 cm (range, 4–28 cm). The technical success was 98%. Mean follow-up was 302 days. The primary stent patency rates were 92%, 76%, 66%, and 60% at 6, 12, 18, and 24 months, respectively.160 Ferreira and colleagues treated 59 patients who had | Surgery_Schwartz. roles in the outcomes. Additionally, stent characteristics may contribute to the patency rate. Several recent clinical studies have demonstrated significant improve-ments in patency when the newer generations of nitinol stents are used to treat SFA lesions.160,200Mewissen treated 137 lower limbs in 122 patients with CLI, secondary to TASC A (n = 12) or TASC B or C (n = 125) lesions in the SFA. Patients were treated with Cordis SMART self-expanding nitinol stents. Binary restenosis (>50%) was measured by standard duplex velocity criteria at various postint-ervention intervals. Primary stent patency, defined as absence of binary restenosis in this study, was calculated by life-table methods from the time of intervention. The mean lesion length was 12.2 cm (range, 4–28 cm). The technical success was 98%. Mean follow-up was 302 days. The primary stent patency rates were 92%, 76%, 66%, and 60% at 6, 12, 18, and 24 months, respectively.160 Ferreira and colleagues treated 59 patients who had |
Surgery_Schwartz_6493 | Surgery_Schwartz | was 98%. Mean follow-up was 302 days. The primary stent patency rates were 92%, 76%, 66%, and 60% at 6, 12, 18, and 24 months, respectively.160 Ferreira and colleagues treated 59 patients who had 74 femoropopliteal lesions (60% TASC D) with Zilver nitinol self-expanding stents (Cook, Bloomington, IN). Mean recanalization length was 19 cm (range, 3–53 cm). Mean fol-low-up time was 2.4 years (range, 3 days–4.8 years). Kaplan-Meier estimates for primary patency rates were 90%, 78%, 74%, 69%, and 69% at 1, 2, 3, 4, and 4.8 years, respectively.201There is general agreement that for suboptimal PTA of an SFA lesion, stent placement is indicated, but a recent random-ized trial by Schillinger and associates suggests that primary stenting results in lower restenosis rates than PTA and selective stenting. Restenosis rates at 2 years were 45.7% versus 69.2% in favor of primary stenting compared with PTA and optional secondary stenting using an intent-to-treat analysis (P = 0.031). Consistently, | Surgery_Schwartz. was 98%. Mean follow-up was 302 days. The primary stent patency rates were 92%, 76%, 66%, and 60% at 6, 12, 18, and 24 months, respectively.160 Ferreira and colleagues treated 59 patients who had 74 femoropopliteal lesions (60% TASC D) with Zilver nitinol self-expanding stents (Cook, Bloomington, IN). Mean recanalization length was 19 cm (range, 3–53 cm). Mean fol-low-up time was 2.4 years (range, 3 days–4.8 years). Kaplan-Meier estimates for primary patency rates were 90%, 78%, 74%, 69%, and 69% at 1, 2, 3, 4, and 4.8 years, respectively.201There is general agreement that for suboptimal PTA of an SFA lesion, stent placement is indicated, but a recent random-ized trial by Schillinger and associates suggests that primary stenting results in lower restenosis rates than PTA and selective stenting. Restenosis rates at 2 years were 45.7% versus 69.2% in favor of primary stenting compared with PTA and optional secondary stenting using an intent-to-treat analysis (P = 0.031). Consistently, |
Surgery_Schwartz_6494 | Surgery_Schwartz | Restenosis rates at 2 years were 45.7% versus 69.2% in favor of primary stenting compared with PTA and optional secondary stenting using an intent-to-treat analysis (P = 0.031). Consistently, stenting, both primary and selective, was supe-rior to standalone PTA with respect to the occurrence of reste-nosis (49.2% vs. 74.3%; P = 0.028) by a treatment-received analysis.202Nitinol bare metal stents that are designed specifically for below-knee interventions are showing very encouraging results. Bosiers and colleagues reported their 12-month results using the commercially available non–drug-eluting Xpert (Abbott Vascular, Santa Clara, CA) nitinol stent system in below-knee arterial interventions.203 They had a 12-month primary patency rate of 76.3% and a limb salvage rate of 95.9%. They fol-lowed patients for 12 months and performed angiography with quantitative vessel analysis on the 73% of patients available. Angiography revealed a binary restenosis rate (>50%) of only 20.5%, which is | Surgery_Schwartz. Restenosis rates at 2 years were 45.7% versus 69.2% in favor of primary stenting compared with PTA and optional secondary stenting using an intent-to-treat analysis (P = 0.031). Consistently, stenting, both primary and selective, was supe-rior to standalone PTA with respect to the occurrence of reste-nosis (49.2% vs. 74.3%; P = 0.028) by a treatment-received analysis.202Nitinol bare metal stents that are designed specifically for below-knee interventions are showing very encouraging results. Bosiers and colleagues reported their 12-month results using the commercially available non–drug-eluting Xpert (Abbott Vascular, Santa Clara, CA) nitinol stent system in below-knee arterial interventions.203 They had a 12-month primary patency rate of 76.3% and a limb salvage rate of 95.9%. They fol-lowed patients for 12 months and performed angiography with quantitative vessel analysis on the 73% of patients available. Angiography revealed a binary restenosis rate (>50%) of only 20.5%, which is |
Surgery_Schwartz_6495 | Surgery_Schwartz | patients for 12 months and performed angiography with quantitative vessel analysis on the 73% of patients available. Angiography revealed a binary restenosis rate (>50%) of only 20.5%, which is comparable to well-accepted coronary drug-eluting stent study outcomes. The authors attributed this opti-mal performance to the maintenance of flow dynamics because Brunicardi_Ch23_p0897-p0980.indd 96827/02/19 4:15 PM 969ARTERIAL DISEASECHAPTER 23the stent was specifically designed for use in small vessels. Kickuth and colleagues also have obtained good results using the Xpert stent. After stent placement, the primary cumulative patency rate at 6 months for the study group of 35 patients was 82%. The sustained clinical improvement rate as evidenced by improved ABI was 80%, and freedom from major amputation was 100% at the 6-month follow-up. The rate of major compli-cations was 17%.204Wolf and colleagues published a multicenter, prospec-tive randomized trial comparing PTA with bypass in 263 | Surgery_Schwartz. patients for 12 months and performed angiography with quantitative vessel analysis on the 73% of patients available. Angiography revealed a binary restenosis rate (>50%) of only 20.5%, which is comparable to well-accepted coronary drug-eluting stent study outcomes. The authors attributed this opti-mal performance to the maintenance of flow dynamics because Brunicardi_Ch23_p0897-p0980.indd 96827/02/19 4:15 PM 969ARTERIAL DISEASECHAPTER 23the stent was specifically designed for use in small vessels. Kickuth and colleagues also have obtained good results using the Xpert stent. After stent placement, the primary cumulative patency rate at 6 months for the study group of 35 patients was 82%. The sustained clinical improvement rate as evidenced by improved ABI was 80%, and freedom from major amputation was 100% at the 6-month follow-up. The rate of major compli-cations was 17%.204Wolf and colleagues published a multicenter, prospec-tive randomized trial comparing PTA with bypass in 263 |
Surgery_Schwartz_6496 | Surgery_Schwartz | amputation was 100% at the 6-month follow-up. The rate of major compli-cations was 17%.204Wolf and colleagues published a multicenter, prospec-tive randomized trial comparing PTA with bypass in 263 men who had iliac, femoral, or popliteal artery obstruction.205 In 56 patients, cumulative 1-year primary patency rate was 43% after PTA and 82% after bypass surgery, demonstrating that for long SFA stenoses or occlusions, surgery is better than PTA. Another recent randomized study (BASIL trial) of 452 patients with CLI demonstrated no difference in amputation-free survival at 6 months between surgery and PTA/stenting.206 The authors com-mented that surgery was somewhat more expensive and rec-ommended that endovascular intervention should be used as first-line therapy especially in medically unfit patients. They did conclude that at the 2-year follow-up, healthy patients with-out medical comorbidities derived greater benefit from surgery because it was associated with decreased need for | Surgery_Schwartz. amputation was 100% at the 6-month follow-up. The rate of major compli-cations was 17%.204Wolf and colleagues published a multicenter, prospec-tive randomized trial comparing PTA with bypass in 263 men who had iliac, femoral, or popliteal artery obstruction.205 In 56 patients, cumulative 1-year primary patency rate was 43% after PTA and 82% after bypass surgery, demonstrating that for long SFA stenoses or occlusions, surgery is better than PTA. Another recent randomized study (BASIL trial) of 452 patients with CLI demonstrated no difference in amputation-free survival at 6 months between surgery and PTA/stenting.206 The authors com-mented that surgery was somewhat more expensive and rec-ommended that endovascular intervention should be used as first-line therapy especially in medically unfit patients. They did conclude that at the 2-year follow-up, healthy patients with-out medical comorbidities derived greater benefit from surgery because it was associated with decreased need for |
Surgery_Schwartz_6497 | Surgery_Schwartz | unfit patients. They did conclude that at the 2-year follow-up, healthy patients with-out medical comorbidities derived greater benefit from surgery because it was associated with decreased need for reintervention and had a decreased hazard ratio in terms of all-cause mortality. The recently published randomized prospective study compar-ing the treatment of SFA occlusive disease percutaneously with an ePTFE/nitinol self-expanding stent graft versus surgical fem-oral to above-knee popliteal artery bypass with synthetic graft material showed no difference between the two groups with respect to primary or secondary patency rate at four years.167 This finding suggests that ePTFE/nitinol self-expanding stent graft placement can be offered as an alternative to treatment of the SFA segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable. Using the 2000 TASC definitions and a Markov state transi-tion model decision analysis, Nolan and | Surgery_Schwartz. unfit patients. They did conclude that at the 2-year follow-up, healthy patients with-out medical comorbidities derived greater benefit from surgery because it was associated with decreased need for reintervention and had a decreased hazard ratio in terms of all-cause mortality. The recently published randomized prospective study compar-ing the treatment of SFA occlusive disease percutaneously with an ePTFE/nitinol self-expanding stent graft versus surgical fem-oral to above-knee popliteal artery bypass with synthetic graft material showed no difference between the two groups with respect to primary or secondary patency rate at four years.167 This finding suggests that ePTFE/nitinol self-expanding stent graft placement can be offered as an alternative to treatment of the SFA segment for revascularization when prosthetic bypass is being considered or when autologous conduit is unavailable. Using the 2000 TASC definitions and a Markov state transi-tion model decision analysis, Nolan and |
Surgery_Schwartz_6498 | Surgery_Schwartz | when prosthetic bypass is being considered or when autologous conduit is unavailable. Using the 2000 TASC definitions and a Markov state transi-tion model decision analysis, Nolan and colleagues showed that PTA/stenting surpasses bypass efficacy for TASC C lesions if PTA/stenting primary patency is >32% at 5 years, patient age is >80 years, and/or greater saphenous vein bypass operative mortality is >6%.207NONATHEROSCLEROTIC DISORDERS OF BLOOD VESSELSThe majority of cases of peripheral vascular disease that are seen by vascular surgeons are attributable to underlying athero-sclerosis. Nonatherosclerotic disease states that result in arterial pathology are less commonly encountered, but are nonetheless important, as they are potentially treatable lesions that may mimic atherosclerotic lesions and result in vascular insuffi-ciency (see Table 23-18). A thorough knowledge of these rare disease states is important for the practicing vascular surgeon in order to make medical | Surgery_Schwartz. when prosthetic bypass is being considered or when autologous conduit is unavailable. Using the 2000 TASC definitions and a Markov state transi-tion model decision analysis, Nolan and colleagues showed that PTA/stenting surpasses bypass efficacy for TASC C lesions if PTA/stenting primary patency is >32% at 5 years, patient age is >80 years, and/or greater saphenous vein bypass operative mortality is >6%.207NONATHEROSCLEROTIC DISORDERS OF BLOOD VESSELSThe majority of cases of peripheral vascular disease that are seen by vascular surgeons are attributable to underlying athero-sclerosis. Nonatherosclerotic disease states that result in arterial pathology are less commonly encountered, but are nonetheless important, as they are potentially treatable lesions that may mimic atherosclerotic lesions and result in vascular insuffi-ciency (see Table 23-18). A thorough knowledge of these rare disease states is important for the practicing vascular surgeon in order to make medical |
Surgery_Schwartz_6499 | Surgery_Schwartz | lesions and result in vascular insuffi-ciency (see Table 23-18). A thorough knowledge of these rare disease states is important for the practicing vascular surgeon in order to make medical recommendations and provide appropri-ate surgical treatment.Giant Cell Arteritis (Temporal Arteritis)Giant cell arteritis is also known as temporal arteritis, which is a systemic chronic inflammatory vascular disease with many characteristics similar to those of Takayasu’s disease. The histo-logic and pathologic changes and laboratory findings are similar. Patients tend to be white women over the age of 50 years, with a high incidence in Scandinavia and women of Northern European descent. Genetic factors may play a role in disease pathogenesis, with a human leukocyte antigen (HLA) variant having been identified. Differences exist between Takayasu’s and giant cell arteritis in terms of presentation, disease location, and therapeutic efficacy. The inflammatory process typically involves the aorta and | Surgery_Schwartz. lesions and result in vascular insuffi-ciency (see Table 23-18). A thorough knowledge of these rare disease states is important for the practicing vascular surgeon in order to make medical recommendations and provide appropri-ate surgical treatment.Giant Cell Arteritis (Temporal Arteritis)Giant cell arteritis is also known as temporal arteritis, which is a systemic chronic inflammatory vascular disease with many characteristics similar to those of Takayasu’s disease. The histo-logic and pathologic changes and laboratory findings are similar. Patients tend to be white women over the age of 50 years, with a high incidence in Scandinavia and women of Northern European descent. Genetic factors may play a role in disease pathogenesis, with a human leukocyte antigen (HLA) variant having been identified. Differences exist between Takayasu’s and giant cell arteritis in terms of presentation, disease location, and therapeutic efficacy. The inflammatory process typically involves the aorta and |
Surgery_Schwartz_6500 | Surgery_Schwartz | Differences exist between Takayasu’s and giant cell arteritis in terms of presentation, disease location, and therapeutic efficacy. The inflammatory process typically involves the aorta and its extracranial branches, of which the superficial temporal artery is specifically affected.The clinical syndrome begins with a prodromal phase of constitutional symptoms, including headache, fever, malaise, and myalgias. The patients may be initially diagnosed with coexisting polymyalgia rheumatica; an HLA-related associa-tion may exist between the two diseases. As a result of vascular narrowing and end-organ ischemia, complications may occur such as visual alterations, including blindness and mural weak-ness, resulting in acute aortic dissection that may be devastating. Ischemic optic neuritis resulting in partial or complete blindness occurs in up to 40% of patients and is considered a medical emergency. Cerebral symptoms occur when the disease process extends to the carotid arteries. Jaw | Surgery_Schwartz. Differences exist between Takayasu’s and giant cell arteritis in terms of presentation, disease location, and therapeutic efficacy. The inflammatory process typically involves the aorta and its extracranial branches, of which the superficial temporal artery is specifically affected.The clinical syndrome begins with a prodromal phase of constitutional symptoms, including headache, fever, malaise, and myalgias. The patients may be initially diagnosed with coexisting polymyalgia rheumatica; an HLA-related associa-tion may exist between the two diseases. As a result of vascular narrowing and end-organ ischemia, complications may occur such as visual alterations, including blindness and mural weak-ness, resulting in acute aortic dissection that may be devastating. Ischemic optic neuritis resulting in partial or complete blindness occurs in up to 40% of patients and is considered a medical emergency. Cerebral symptoms occur when the disease process extends to the carotid arteries. Jaw |
Surgery_Schwartz_6501 | Surgery_Schwartz | resulting in partial or complete blindness occurs in up to 40% of patients and is considered a medical emergency. Cerebral symptoms occur when the disease process extends to the carotid arteries. Jaw claudication and temporal artery tenderness may be experienced. Aortic lesions are usually asymptomatic until later stages and consist of thoracic aneu-rysms and aortic dissections.The diagnostic gold standard is a temporal artery biopsy, which will show the classic histologic findings of multinucle-ated giant cells with a dense perivascular inflammatory infil-trate. Treatment regimens are centered on corticosteroids, and giant cell arteritis tends to rapidly respond. Remission rates are high, and treatment tends to have a beneficial and preventative effect on the development of subsequent vascular complications.Takayasu’s ArteritisTakayasu’s arteritis is a rare but well-recognized chronic inflam-matory arteritis affecting large vessels, predominantly the aorta and its main branches | Surgery_Schwartz. resulting in partial or complete blindness occurs in up to 40% of patients and is considered a medical emergency. Cerebral symptoms occur when the disease process extends to the carotid arteries. Jaw claudication and temporal artery tenderness may be experienced. Aortic lesions are usually asymptomatic until later stages and consist of thoracic aneu-rysms and aortic dissections.The diagnostic gold standard is a temporal artery biopsy, which will show the classic histologic findings of multinucle-ated giant cells with a dense perivascular inflammatory infil-trate. Treatment regimens are centered on corticosteroids, and giant cell arteritis tends to rapidly respond. Remission rates are high, and treatment tends to have a beneficial and preventative effect on the development of subsequent vascular complications.Takayasu’s ArteritisTakayasu’s arteritis is a rare but well-recognized chronic inflam-matory arteritis affecting large vessels, predominantly the aorta and its main branches |
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