The morbidity and mortality rates associated with late removal of endografts are significant. Removal of Vanguard devices can necessitate extension of the aortotomy above the renal arteries. We believe that control of the aorta well above the proximal fixation site is the key to removal and that continuous aortic exposure via retroperitoneal exposure is the best option in this situation.
One hundred seventy-seven patients with infrainguinal bypass grafts were followed by use of standard graft surveillance techniques to learn more about the natural history of hemodynamic abnormalities in the patient with no symptoms. A decrease in the ankle/brachial pressure ratio of 10% or more was considered an abnormal evaluation. Results of the duplex scan were interpreted as abnormal when the peak systolic flow velocity was greater than 120 cm/sec or less than 40 cm/sec. There were 18 graft thromboses (10%) during the period of observation, and nine of these grafts were successfully revised or replaced. Recurrent symptoms prompted graft revision in 20 additional patients, and 18 of these reoperations were successful. Twenty-nine of the 38 reoperations occurred within the first 18 months of the study. The primary cumulative patency rate was 86% at 1 year and 66% at 5 years. The secondary cumulative patency rate was 91% at 1 year and 80% at 5 years. Sudden graft occlusion occurred in five patients after a normal ankle/brachial index. Most of 90 patients with abnormal ankle/brachial indexes reverted to normal at the next visit. Nineteen of the 26 that did not, had significant graft problems, but only eight patients had operable conditions, and five of the eight already had occluded grafts. No patient with a normal ankle/brachial index and duplex scan results had graft occlusion before their next surveillance visit. If the duplex scan outcome was abnormal but the ankle/branchial index normal the incidence of sudden graft occlusion was 4%. In contrast, if the duplex scan outcome was abnormal and the ankle/brachial index is reduced, then the risk of graft occlusion is 66%.(ABSTRACT TRUNCATED AT 250 WORDS)
Over a 5-year period 642 patients underwent 686 carotid endarterectomies with patch closure and intraoperative surveillance with continuous-wave Doppler. The perioperative stroke rate was 1.5%. Patients were screened with duplex scans immediately after operation for the presence of residual carotid lesions, and followed every 3 to 6 months for either the development of a true recurrent lesion or a change in a residual one. Five hundred thirty-nine arteries (84%) had no postoperative abnormalities. The incidence of recurrent carotid lesions in this groups was 1.5%, 3.4%, and 5.2% at 1, 2, and 3 years, respectively. The incidence of symptoms in this group was 0.2%, 0.7%, and 1.4% at 1, 2, and 3 years, respectively. The earliest recurrence or symptom occurred 8 months from operation. One hundred forty-seven arteries had residual lesions that were more common when either a temporary shunt was used or the operation was carried out above the hypoglossal nerve or below the omohyoid muscle. Sixty-one patients who had plaque proximal to the arteriotomy without a significant stenosis were followed an average of 21 months. There were no changes in plaque morphology and no proven symptoms related to the residual lesion. Fifty-six patients with both plaque and significant hemodynamic abnormalities in the carotid bulb were followed an average of 18 months. Seven of these patients (12.5%) had either a significant deterioration of the lesion or a symptom from it. Each event occurred within 6 months of operation. Thirty patients had significant flow abnormalities but no visible plaque. None of these lesions deteriorated. Although common, residual carotid lesions are benign unless the lesion is characterized by both plaque within the artery and a hemodynamically significant stenosis. These lesions should be further investigated and treated when discovered.
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