Despite the widespread use of intraarterial thrombolytic therapy for peripheral arterial occlusive disease, a randomized study comparing its efficacy with that of operative intervention has never• been performed. This study evaluates the potential of intraarterial urokinase infusion to provide clinical benefits in patients with acute peripheral arterial occlusion. Methods: Patients with limb-threatening ischemia of less than 7 days' duration were randomly assigned to intraarterial catheter-directed urokinase therapy or operative intervention. Anatomic lesions unmasked by thrombolysis were treated with balloon dilation or operation. The primary end points of the study were limb salvage and survival.Results: A total of 57 patients were randomized to the thrombolytic therapy group, and 57 patients were randomized to the operative therapy group. Thrombolytic therapy resulted in dissolution of the occluding thrombus in 40 (70%) patients. Although the cumulative limb salvage rate was similar in the two treatment groups (82% at 12 months), the cumulative survival rate was significandy improved in patients randomized to the thrombolysis group (84% vs 58% at 12 months, p = 0.01). The mortality differences seemed to be primarily attributable to an increased frequency of in-hospital cardiopulmonary complications in the operative treatment group (49% vs 16%, P = 0.001). The benefits of thrombolysis were achieved without significant differences in the duration of hospitalization (median 11 days) and with only modest increases in hospital cost in the thrombolytic treatment arm (median $15,672 vs $12,253, P = 0.02).Conclusions: Intraarterial thrombolytic therapy was associated with a reduction in the incidence of in-hospital cardiopulmonary complications and a corresponding increase in patient survival rates. These benefits were achieved without an appreciable increase in the duration of hospitalization and with only modest increases in hospital cost, suggesting that thrombolytic therapy may offer a safe and effective alternative to operation in the initial treatment of patients diagnosed with acute limb-threatening peripheral arterial occlusion.

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One third of all patients who survive AAA repair experience significant dilatation of their proximal aortic cuff over time. Proximal dilatation is rare but not absent in patients who have smaller initial aortic cuff diameters. This dilatation rarely causes problems after conventional suture fixation, but the long-term implications of cuff dilatation after endoluminal repair are unclear. Our findings suggest that endovascular aortic prostheses that have the ability to continue to self-expand many years after implantation may be required and that endovascular prostheses may not be the best option for patients who have a long life expectancy or for those who have preoperative proximal cuffs greater than 27 mm.

Operative repair was undertaken for 51 popliteal aneurysms in 39 patients between 1958 and 1990. Operation was performed on an emergency basis in 19 extremities with limb-threatening ischemia and as an elective procedure in 32 extremities. Cumulative limb salvage (94%) rates and patency rates (67%) became significantly different at 6 years (p less than 0.05). Graft patency was affected by clinical presentation and runoff. After 1 year, cumulative patency for extremities with limb-threatening ischemia was significantly lower than for those having an elective operation (69% vs 100%, p less than 0.05). Runoff did not influence graft patency until 3 years, at which time cumulative patency was better in extremities with good runoff than in extremities with poor runoff (89% vs 30%, p less than 0.05). Limb salvage was affected only by presentation. All limb loss (three patients) occurred within the first month in extremities with graft occlusion after operation for limb-threatening ischemia. Runoff did not influence patency rates for extremities with limb-threatening ischemia, since no difference was observed in runoff between the two groups. We conclude that elective repair is indicated in all patients with popliteal aneurysms. It is associated with little risk to the patient, and prevents the need for operation in the setting of limb-threatening ischemia with its poorer overall results and definite incidence of amputation.

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We have used clamping of the aorta above the celiac axis (SC) in 30 of 431 elective resections of infrainguinal abdominal aortic aneurysms (AAA) during the past five years as an alternative to a difficult aortic cuff dissection. The results of SC clamping in these 30 patients are compared with the results of 379 routine aneurysm resections with infrarenal (IR) clamping and 22 additional aneurysm resections where the clamp was placed immediately above the renal arteries. These difficult cuff dissections occurred in 12 patients with inflammatory AAA, in 11 patients with juxtarenal AAA, and in seven patients with recurrent or noninfected false AAA of the proximal cuff. Patients with ruptured or suprarenal aneurysms and those undergoing combined operation for a visceral ischemic syndrome and an aneurysm were excluded from this study. Patients with SC clamping had similar operative mortality rates, comparable renal function, and frequency of cardiac events as patients with IR clamping. Blood loss was slightly higher in the SC group (p = 0.07) and serum aspartate amino transferase (AST) levels were three times higher than in the IR group; however, this was of no clinical significance. In contrast, those 22 patients whose aortas were clamped immediately above the renal arteries (AR) had higher perioperative mortality rates (2% IR, 3% SC vs 32% AR) and a higher incidence of kidney failure requiring dialysis (1% IR, 3% SC vs 23% AR). The mean values of serum creatinine and blood urea nitrogen were also significantly higher in the AR group when compared with both the IR and the SC groups (IR: 25 and 1.5 mg/dl, respectively; SC: 27 and 1.8 mg/dl; AR: 41 and 3.5 mg/dl). The single most important risk factor accounting for the differences between clamping above the celiac artery and clamping above the renal arteries was the presence of atherosclerotic debris in the nonaneurysmal, juxtarenal aortic segment. Clamping the aorta with juxtarenal atherosclerosis caused either atheroembolization to kidneys, legs, and intestine or injury to the aorta, renal arteries, or both; it was the cause of morbidity in all five cases of kidney failure requiring dialysis and accounted for all seven of the deaths in the AR group. SC clamping does not add risk to the patient undergoing resection of an infrarenal AAA and is the preferred method of achieving proximal control of the infrarenal aorta when a a hazardous cuff dissection is likely.(ABSTRACT TRUNCATED AT 400 WORDS)

A 5-year experience with 562 carotid endarterectomies, using electroencephalogram (EEG) monitoring and selective shunting, was reviewed. EEG changes occurred in 102 patients (18%). The frequency of EEG changes, as related to cerebral vascular symptoms, was as follows: transient ischemic attacks, seven per cent (19/259); completed strokes, 37% (36/98); vertebral basilar insufficiency, 24% (32/135); asymptomatic, 21% (15/71). Patients with contralateral carotid occlusion exhibited EEG changes in 37% (28/76) of operations. Fifteen patients suffered perioperative strokes (2.6%). Nine of the 15 were associated with a technical problem of either thrombosis of the internal carotid artery (five) or emboli (four). Technical problems were more common when shunts were used (five per cent) than when they were not (0.9%). Patients who suffered strokes prior to surgery were more at risk to develop a perioperative stroke (three per cent) than those not suffering prior strokes (0.3%). The EEG did not change in three patients who had lacunar infarcts prior to surgery and who awoke with a worsened deficit. Our series does not clearly establish the advantages of EEG monitoring, which is expensive (+375/patient) and may not detect ischemia in all areas of the brain. However, the use of shunts may introduce a risk of stroke due to technical error that is equal or greater than the risk of stroke due to hemodynamic ischemia. Since the need for protection is unpredictable by angiographic or clinical criteria, the benefit of EEG monitoring may be in reducing the incidence of shunting in those patients whose tracing remains normal after clamping. The decision to shunt, however, when there is electrical dysfunction after carotid clamping should be based not only on the EEG but also on the clinical signs and computed tomography (CT) scan. Our data does not show a net benefit in selective shunting unless the patient has sustained a stroke prior to surgery.

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