Papers by Frank Pomposelli
European Journal of Vascular and Endovascular Surgery, 2019
Annals of vascular surgery, 2010
Patients undergoing lower extremity bypass are at high risk for surgical site infections (SSI). W... more Patients undergoing lower extremity bypass are at high risk for surgical site infections (SSI). We examined lower extremity bypasses by graft origin and body mass index (BMI) classification to analyze differences in postoperative mortality and SSI occurrence. The 2005-2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was queried to compare perioperative mortality (30-day), overall morbidity, and SSIs after lower extremity arterial bypass for peripheral arterial disease. Bypass was stratified by graft origin as aortoiliac, femoral, or popliteal. Patient demographics, comorbidities, operative, and postoperative occurrences were analyzed. There were 7,595 bypasses performed (1,596 aortoiliac, 5,483 femoral, and 516 popliteal). Mortality was similar regardless of bypass origin (2.8%, 2.4%, and 2.7%; p = 0.57). SSIs occurred in 11% of overall cases (10%, 11%, and 11%; p = 0.47). Graft failure was significantly associated with postop...
Journal of Vascular Surgery, 2009
Background: Thoracic endovascular aortic repair (TEVAR) is a minimally invasive alternative to op... more Background: Thoracic endovascular aortic repair (TEVAR) is a minimally invasive alternative to open repair of many thoracic aortic pathologies. Most of the published data to date involve a relatively limited number of individuals and follow-up. In this descriptive study, we report our midterm outcomes of a large, decade-long, single-center TEVAR experience. Methods: A prospectively maintained TEVAR registry and electronic medical records at a tertiary care center were retrospectively analyzed for patient characteristics, intraoperative details, and early and late postoperative outcomes. Results: From 2000 to 2009, 400 consecutive TEVARs were performed using seven endograft systems (TAG, 65%; TX2, 18%; Talent, 6%; aortic cuff, 3%; and investigational, 8%). More than 91% were performed in the last 5 years of the study. The distribution of pathologies treated included 198 aneurysms (50%), 100 dissections (25%), 54 penetrating ulcers (13%), 25 traumatic transections (6%), and 23 other pathologies (6%). Dissections represented the single fastest growing segment being treated. Men comprised 69%, the mean age was 65 Ϯ 16 years, and 18% had had prior abdominal aortic replacements. Thirty-two percent of cases were performed urgently or emergently. Sixty-nine percent were American Society of Anesthesiology class IV, and 61% underwent general anesthesia. Spinal drains were prophylactically placed in 127 cases (32%) of planned extended aortic coverage. There were no acute surgical conversions. Mean number of devices was 2.3 Ϯ 1.1, and 63% of cases were completed with one or two devices. Mean fluoroscopy was 24 Ϯ 15 minutes, contrast was 139 Ϯ 54 mL, blood loss was 309 Ϯ 316 mL, and procedure time was 116 Ϯ 5 minutes. Sixteen percent required iliac conduits. Fifty-one percent of proximal landing zones involved zones 0 to 2. Preoperative adjunctive surgical procedures were performed on 94 patients (24%). These included arch debranching in 22 (6%), first-stage elephant trunk in 20 (5%), visceral debranching in 21 (5%), and left subclavian revascularization in 31 (8%). Subclavian revascularizations were selectively performed in only 17% of zone 2 deployments. The median length of stay was 5 days (range, 1-79 days). Incidence of type I/III endoleak was 10% and 5% at 1 and 12 months, respectively. Overall 30-day mortality was 6.5% (elective, 2.6%; urgent, 9.5%; emergent, 20%). Permanent spinal cord ischemia occurred in 3.6% and stroke in 2.1%. Kaplan-Meier estimates of survival were 81%, 76%, and 69%, and freedom from secondary intervention were 90%, 86%, and 82% at 6, 12, and 24 months, respectively. Conclusions: Since commercial availability of thoracic endografts, TEVAR has been used to treat a variety of thoracic aortic pathologies, many of which were off-label. With careful planning and technique, the procedures can be performed with virtually zero risk of intraoperative conversion. Although overall rates of mortality and neurologic complications were relatively low, they were significantly increased in emergency repairs. There appears to be substantial number of late deaths that may represent a combination of poor patient selection or treatment failures.
Journal of Vascular Surgery, 2009
Background: Lower extremity bypass graft failure in patients with limb-threatening ischemia carri... more Background: Lower extremity bypass graft failure in patients with limb-threatening ischemia carries an amputation rate of greater than 50%. Redo bypass is often difficult due to the lack of conduit, adequate target, or increased surgical risk, and resultant limb salvage rates are reduced significantly compared with the index operation. We set forth to investigate whether endovascular treatment in this setting would result in an acceptable limb salvage rate. Methods: A single-institution, retrospective review from June 2004 to December 2007 of patients with failed grafts who underwent endovascular treatment with percutaneous balloon angioplasty (PTA) of their native circulation was performed. Stents were selectively used in cases of post-PTA residual stenosis or flow-limiting dissection. Technical success was defined as a residual stenosis less than 30%. Percutaneous attempts at bypass graft salvage were excluded. Demographics, comorbidities, procedural data, and follow-up information were recorded. Descriptive, logistic regression and life-table analyses were performed. Results: Twenty-four lower extremities were treated in 23 patients with failed bypass grafts. Average patency of the index graft before failure was 647 days (range 5-2758). Mean age was 68 years (range 51-85), 62% were male and 81% had diabetes mellitus (DM). 87.5% of limbs treated had TransAtlantic InterSociety Consensus (TASC) C and D lesions and 62% had multiple lesions. Technical success was achieved in 100%. Mean follow-up was 25.6 months. At follow-up, there were 17 PTA failures, which resulted in: amputation (4), redo-bypass (3), and redo-PTA (11). Freedom from surgical revision and PTA failure was 89% (؉/؊ 0.07 SE) and 28% (؉/؊ 0.09 SE) respectively. PTA secondary patency was 72% (؉/؊ 0.09 SE) and limb-salvage was 81% (؉/؊ 0.08 SE) at both 12 and 24 months. Overall survival was 83% (؉/؊ 0.07 SE) and 77% (؉/؊ 0.09 SE) at 12 and 24 months, respectively. Conclusions: Endovascular treatment of patients with previously failed bypass grafts results in a high rate of limb salvage. This is a reasonable option in selected patients and the primary choice in those with poor targets, conduit, or excess surgical risk. Endovascular salvage should be considered before proceeding to primary amputation.
Journal of Vascular Surgery, 2003
The purpose of this study was to review our experience over the last decade with the dorsalis ped... more The purpose of this study was to review our experience over the last decade with the dorsalis pedis bypass for ischemic limb salvage in patients with diabetes mellitus. Methods: The study was a retrospective analysis of a computerized vascular registry and chart review. From January 10, 1990 to January 11, 2000, 1032 bypasses to the dorsalis pedis artery were performed in 865 patients (27.6% of the 3731 lower extremity arterial bypass procedures performed in that time period). Five hundred ninety-seven patients (69%) were male, with a mean age of 66.8 years. Ninety-two percent had diabetes mellitus. All procedures were done for limb salvage. Conduits included 317 nonreversed saphenous vein (30.7%), 273 in situ (26.4%), 235 reversed vein (22.8%), 170 arm vein (16.5%), 35 other vein (3.4%), and two polytetrafluoroethylene (0.2%) grafts. The inflow arteries were as follows: 294 common femoral (28.5%), 550 popliteal (53.2%), 114 superficial femoral (11%), and 74 other (7.2%). Results: The mortality rate within 1 month of surgery was 0.9%, and 42 grafts (4.2%) failed in the same interval, although 13 were successfully revised. In a follow-up period that ranged from 1 to 120 months (mean, 23.6 months), primary patency, secondary patency, limb salvage, and patient survival rates were 56.8%, 62.7%, 78.2%, and 48.6%, respectively at 5 years and 37.7%, 41.7%, 57.7%, and 23.8% at 10 years. Both polytetrafluoroethylene grafts failed in less than 1 year. Primary graft patency was worse in female patients (46.5% female versus 61.6% male at 5 years; P < .009) but better in patients with diabetes (65.9% diabetes mellitus versus 56.3% non-diabetes mellitus at 4 years; P < .04). Saphenous vein grafts performed better than all other conduits with a secondary patency rate of 67.6% versus 46.3% at 5 years (P < .0001). Multivariate analysis showed that length of stay greater than 10 days and dorsalis pedis bypass for the surgical indication of previous graft occlusion were independently predictive of worse graft patency at 1 year and use of saphenous vein as conduit was predictive of better patency. Conclusion: Dorsalis pedis bypass is durable with a high likelihood of ischemic foot salvage over many years. Saphenous vein is the preferred conduit when available. Short vein grafts from distal inflow sites are possible in more than 50% of cases. These results justify the routine use of pedal arterial reconstruction for patients with diabetes with ischemic foot complications.
Journal of Vascular Surgery, 2000
The absence of an adequate ipsilateral saphenous vein in patients requiring lower-extremity revas... more The absence of an adequate ipsilateral saphenous vein in patients requiring lower-extremity revascularization poses a difficult clinical dilemma. This study examined the results of the use of autogenous arm vein bypass grafts in these patients. Methods: Five hundred twenty lower-extremity revascularization procedures performed between 1990 and 1998 were followed prospectively with a computerized vascular registry. The arm vein conduit was prepared by using intraoperative angioscopy for valve lysis and identification of luminal abnormalities in 44.8% of cases. Results: Seventy-two (13.8%) femoropopliteal, 174 (33.5%) femorotibial, 29 (5.6%) femoropedal, 101 (19.4%) popliteo-tibial/pedal, and 144 (27.7%) extension "jump" graft bypass procedures were performed for limb salvage (98.2%) or disabling claudication (1.8%). The average age of patients was 68.5 years (range, 32 to 91 years); 63.1% of patients were men, and 36.9% of patients were women. Eighty-five percent of patients had diabetes mellitus, and 77% of patients had a recent history of smoking. The grafts were composed of a single arm vein segment in 363 cases (69.8%) and of spliced composite vein with venovenostomy in 157 cases (30.2%). The mean follow-up period was 24.9 months (range, 1 month to 7.4 years). Overall patency and limb salvage rates for all graft types were:
Journal of Vascular Surgery, 2005
Objective: Patients undergoing infrainguinal arterial reconstruction frequently have increased ca... more Objective: Patients undergoing infrainguinal arterial reconstruction frequently have increased cardiac risk factors. Diabetic patients are often asymptomatic despite advanced cardiac disease. This study investigates whether preoperative cardiac testing improves the outcome in diabetic patients at risk for cardiac disease. Methods: We retrospectively reviewed all patients undergoing lower-extremity arterial reconstructions in a 32-month period from July 1999 to February 2002. Of the 433 patients identified undergoing 539 procedures, 295 had diabetes mellitus and considered in this study. The patients were stratified into two groups according to the present American College of Cardiology, American Heart Association (ACC/AHA) algorithm. We identified 140 patients with two or more of ACC (Eagle) criteria who met the inclusion criteria for a preoperative cardiac evaluation. These patients were separated into two groups: those undergoing a cardiac work-up (WU) according to the ACC/AHA algorithm and those not undergoing the recommended work-up (NWU). Outcomes included perioperative mortality, postoperative myocardial infarction, congestive heart failure, arrhythmia, and length of hospitalization. Significance of association was assessed by the Fisher exact test. Length of hospitalization was compared using the Kruskal-Wallis rank sum test. Survival data was analyzed with the Kaplan-Meier method. Results: One hundred forty patients met the criteria for moderate risk. There were 61 patients in the NWU group and 79 in the WU group. Ten patients in the WU group underwent preoperative coronary revascularization (6 had percutaneous transluminal coronary angioplasty, 4 underwent coronary artery bypass grafting). There was no difference between perioperative mortality (WU, 1%; NWU, 2%; P ؍ 1.00) or in postoperative cardiac morbidity, including myocardial infarction, congestive heart failure, and arrhythmia requiring treatment (WU, 5%; NWU, 6%; P ؍ .71). There were no perioperative deaths and one episode of congestive heart failure in the group that had preoperative coronary revascularization. Median length of hospitalization was 10 days in the WU group and 8 days in the NWU group (P ؍ .11). Patient survival at 12 months for the NWU, WU, and revascularized groups was 85.3%, 78.5%, and 80.0%, respectively; 36-month survival was 73.6%, 62.9%, and 80.0%, respectively. The three survival curves did not differ significantly (P ؍ .209). Conclusions: Preoperative cardiac evaluation, as defined by the ACC/AHA algorithm, does not predict or improve postoperative morbidity, mortality, or 36-month survival in asymptomatic, diabetic patients undergoing elective lower-extremity arterial reconstruction. These data do not support the current ACC/AHA recommendations as a standard of care for diabetic patients with an intermediate clinical predictor who undergo peripheral arterial reconstruction, a high-risk surgical procedure.
Journal of Vascular Surgery, 1995
The performance of a graft created from the upper arm basilic and cephalic veins in continuity wa... more The performance of a graft created from the upper arm basilic and cephalic veins in continuity was investigated. Methods: Retrospective analysis of 50 patients, who underwent 54 distal reconstructions with an upper arm vein loop graft between February 1989 and October 1993 (male-to-female ratio of 30/20; mean age of 69.2 years, range 39 to 87; 74% had diabetes) was undertaken. Vein grafts were harvested through a near continuous incision, leaving a skin bridge in the cubita. Intraoperative angioscopy was used to exclude endoluminal disease and to directly observe valvulotomy of the nonreversed part of the graft. Results: Operations were performed for limb salvage in 98.2% of 17 primary and 37 reoperative procedures. Eleven femoropopliteal, 33 femorotibial-pedal, seven poplitealdistal, and two outflow jump grafts were performed. The ipsilateral saphenous vein was unavailable because of previous infrainguinal bypass in 35, coronary artery bypass grafting in 14, and unsuitable quality in 5 cases. Thirty.eight grafts were used in continuity, and 16 grafts required repair or splicing with additional vein segments. Primary 30-day patency rate was 92.6% (n = 4 occlusions). No operative deaths occurred. The cumulative patency rate at 1 year was 74.4%, the limb salvage rate 90.7%. Conclusions: The upper arm vein loop is a durable graft with excellent short-term and midterm patency rates. Sufficient vein length can be obtained to reach the below-knee and midtibial levels. Angioscopic quality assessment is a valuable adjunct to exclude endoluminal disease most commonly occurring in the median cubital vein. Straightening the curve of the median cubital vein and val~xtlotomy do not influence patency rates. This is a valuable technique for vascular surgeons that enables rescue of ischemic limbs under otherwise difficult circumstances. (J VASC SURG 1995;21:586-94.) Distal arterial revascularization in the absence of an adequate saphenous vein is a challenging problem in vascular surgery. With aggressive revascularization policies the saphenous vein becomes less often available for distal bypass after previous use for coronary artery bypass or distal revascularization
Journal of Vascular Surgery, 1995
The purpose of this study was to assess functional status, well-being, and symptom relief of pati... more The purpose of this study was to assess functional status, well-being, and symptom relief of patients after infrainguinal revascularization for severe peripheral vascular disease. Methods: Two questionnaires were used to assess symptoms, functional status, and well-being before operation and 6 months after operation. Sociodemographics, comorbidities, indications for surgery, graft location, and morbidity, mortality, patency, and limb salvage rates were obtained via vascular registry. Results: Of 318 patients who underwent revascularization over a 1-year period, 276 patients were asked to complete the questionnaires. Of the 156 patients who completed both questionnaires, mean age was 66 years, 67% were men, 84% had diabetes mellitus, and 83% had various heart-related conditions. Mean length of stay was 15.3 days. Distal graft sites were popliteal (29%), tibial/peroneal (40%), and pedal/plantar (31%). The operative morbidity rate was 21%, the cumulative primary graft patency rate was 93%, the cumulative secondary graft patency rate was 95%, and the limb salvage rate was 97% at 6 months. At follow-up, improved functioning of instrumental activities of daily living, mental well-being, and vitality were reported. Symptoms of calf cramping and toe or foot pain when walking and at rest were also improved. Sores or ulcers improved, but leg swelling did not. The only independent predictor of improved fimction and well-being was the patients' perception of their status at baseline: those patients who functioned better before operation reported improved function and well-being at 6 months. Only 45% of patients reported feeling "back to normal" at 6 months. Conclusion: Reported health status at baseline was a predictor of improved function, mental well-being, and resolution of symptoms after infrainguinal revascularization. Expected return to "normal" may take longer than 6 months. (J VAsc SURG 1995;21: 35.-45.) Helping patients with severe peripheral vascular occlusive disease (PVOD) attain the highest possible level of health, function, and well-being continues to be the goal of vascular surgeons. Health care reform
Journal of Vascular Surgery, 1996
Aggressive policies for distal bypass and coronary revascularization increase the need to identif... more Aggressive policies for distal bypass and coronary revascularization increase the need to identify alternatives to autologous saphenous vein grafts. We examined the performance of arm vein as the primary alternative to contralateral saphenous vein when the ipsilateral saphenous vein was not available. Methods: A total of 250 arm vein grafts were studied retrospectively in 224 patients (143 men, 81 women, 82.6% with diabetes, mean age 68.3 years) from February 1989 to April 1994. Intraoperative angioscopy was carried out to observe valve lysis, remove abnormalities, and select optimal vein segments. Results: A total of 85 primary, 103 repeat, and 62 graft revision procedures were done for limb salvage in 99.2% of the patients. A total of 41 femoropopliteal, 114 femorotibialpedal, 33 popliteodistal, and 62 jump or interposition grafts were constructed. A total of 199 grafts were single vein, and 51 were composite vein. The source was cephalic vein alone in 50.4%, cephalic and basilic vein in 35.6%, and basilic vein only in 14%. The contralateral saphenous vein as an alternative conduit was available in 97 (38.8O/o) instances. Interventions guided by angioscopy to "upgrade" the graft were necessary in 51.6%. Overall early patency (< 30 days) was 94.8% (n = 13 occlusions). The cumulative primary patency rate at 1 year was 70.6%, the secondary patency rate was 76.9%, and the limb salvage rate was 88.2%. The 3-year patency rate (limb salvage) was 51.9% (92.4%) for primary grafts, 56.7% (67.1~ in revision grafts, and 42.4% (79.9%) in repeat grafts. In 22.7% (22 of 97) the available contralateral saphenous vein was used for distal revascularization within the follow-up period. Conclusions: Arm veins are an easily accessible autologous conduit of sufficient length to reach the midtibial level. Excellent patency rates allow durable limb salvage in otherwise difficult circumstances. Vein configuration and splicing do not affect patency rates, but vein quality and repeat operations do. Angioscopy is a valuable adjunct to upgrade graft quality. The contralateral saphenous should be saved for subsequent contralateral revascularization or coronary artery bypass grafting.
Journal of Vascular Surgery, 2002
Objective: Although previous series have reported outcomes of lower extremity (LE) revascularizat... more Objective: Although previous series have reported outcomes of lower extremity (LE) revascularization in patients with end-stage renal disease, the issue of LE bypass for limb salvage in this group has not been resolved. We herein present the largest series to date of a 10-year single-institution experience with LE bypass in patients with dialysis dependence. Methods: With prospectively entered data from a university teaching hospital's vascular registry, we reviewed the records of all patients with dialysis dependence who underwent LE arterial bypass between January 1, 1990, and May 31, 1999. Results: A total of 146 consecutive patients (177 limbs) underwent infrainguinal revascularization, of whom nearly all (92%) had diabetes and tissue loss (91%). The in-hospital mortality rate was 3% (five patients). The rates for perioperative congestive heart failure, myocardial infarction, arrhythmia, and wound infection were 2%, 3%, 5%, and 10%, respectively. The actuarial graft primary and secondary patency rates at 1 and 3 years were 84% and 85%, and 64% and 68%, respectively. The limb salvage rates were 80% and 80% at 1 and 3 years. The 1-year and 3-year cumulative survival rates were 60% and 18%, respectively. At 5 years, survival was poor with only 5% of the entire cohort of 146 patients still alive. Multivariate logistic regression analysis at 6 months identified age (odds ratio, 0.96, 0.91) and number of years on dialysis (odds ratio, 0.79, 0.74) as significant (P < .05) negative predictors of both limb salvage and survival, respectively. Conclusion: Infrainguinal arterial reconstruction can be performed on patients with dialysis dependence with acceptable rates of limb salvage given the high incidence rate of perioperative complications and poor longevity of this patient group. Advanced age and number of years on dialysis seem to correlate with poorer outcome.
Journal of Vascular Surgery, 2009
Percutaneous transluminal angioplasty (PTA) has had an expanding role as primary therapy for vein... more Percutaneous transluminal angioplasty (PTA) has had an expanding role as primary therapy for vein graft stenosis with variable results. The aim of this study is to identify patient and graft characteristics predictive of failure after PTA of infrainguinal vein grafts. Methods: Retrospective review from Jan 2004 to Mar 2007 of patients undergoing angioplasty for failing grafts. Demographics, comorbidities, procedural data, and follow-up information were recorded. PTA failure was defined as first significant event including restenosis by duplex scan (>3.5 ؋ velocity ratio), occlusion, redo-PTA, surgical revision, or amputation. Descriptive, logistic regression and life-table analyses were performed. Results: Eighty-seven grafts in 79 patients underwent PTA. Mean age was 70 years (median 70; range, 39-89 years), 71% were male and 52% were symptomatic (40% with limb-threat). Mean follow-up was 17 months (median 17.4; range, 0.03-39.8 months). Freedom from PTA failure was 58% (standard error [SE] 0.0574) at 12 months. Predictors of PTA failure by multivariate analysis were: time from bypass <3 months (hazard ratio [HR] 5.8; 95% confidence interval [CI] 1.91-18.0; P ؍ .002), stenosis length >2 cm (HR 2.7; 95% CI 1.33-5.83; P ؍ .007) and multiple stenoses (HR 2.5; 95% CI 1.29-5.1; P ؍ .007). PTA patency for grafts with favorable lesions (single, less than 2 cm lesions in grafts older than 3 months) was 71% vs 35% for unfavorable lesions at 12 months. Limb-salvage was 95% and 90% and overall survival was 92% and 81% at 12 and 24 months, respectively. Conclusion: PTA of failing infrainguinal vein grafts is a reasonable primary therapy for favorable lesions. Early graft stenosis, long, and multiple stenoses are markers for procedural failure and are better served with surgical revision.
Journal of Vascular Surgery, 2003
Incidence of perioperative complications is increased and outcome is poor in young patients under... more Incidence of perioperative complications is increased and outcome is poor in young patients undergoing vascular surgery. We extensively reviewed results of lower-extremity procedures in this group of patients to further define the extent of short-term and long-term morbidity. Methods: Results from our vascular registry were retrospectively reviewed for 76 lower-extremity revascularization procedures performed between January 1990 and May 2000 in 51 patients younger than 40 years. This represents 1.88% of 4052 lower-extremity bypass procedures performed during this period. Perioperative cardiac complications, long-term survival, graft patency, and limb salvage were evaluated. Kaplan-Meier curves were generated, and their significance was determined with the Cox-Mantel test. Results: Forty-nine percent of patients were male, and 51% were female; mean age at presentation was 35.9 years (range, 27.5-39.8 years). Preoperative morbidity included diabetes mellitus (96.1%), smoking (70.6%), hypertension (78.4%), coronary artery disease (37.3%), hyperlipidemia (33.3%), and renal dysfunction (52.9%). Overall rate for 30-day postoperative mortality was 0.0%, for myocardial infarction was 0.0%, and for congestive heart failure was 1.32%. Thirty-day graft failure was 11.1% (n ؍ 9). At 1 year, primary patency was 71.0%, secondary patency was 82.5%, and limb salvage was 87.1%; and at 5 years these rates were 51.9%, 63.4%, and 77.2%, respectively. After the initial surgery 11.8% (n ؍ 6) of patients required at least one additional ipsilateral revascularization procedure, 31.3% (n ؍ 16) required a bypass graft in the contralateral limb, and 23.5% (n ؍ 12) ultimately required amputation. In patients who required additional ipsilateral procedures, 1-year primary patency rate was 66.7%, secondary patency rate was 62.5%, and limb salvage rate was 77.8%, compared with 5-year rates of 44.4%, 41.7%, and 64.8%, respectively, representing a decrease in patency compared with primary revascularization procedures. Overall survival at 1 year was 88.2%, compared with 73.3% at 5 years. Patients with preexisting renal disease had significantly decreased survival at 5 years compared with those without renal dysfunction (64.5% vs 82.6%; P ؍ .019). Conclusions: Our data suggest that age younger than 40 years is not associated with increased perioperative morbidity and mortality. However, these patients have a significant rate of early graft failure and dismal long-term survival, especially in patients with preexisting renal dysfunction. In addition, ipsilateral repeat operations have a marginal success rate.
Journal of Vascular Surgery, 1996
Purpose:Although severe, circumferential calcification of distal outflow vessels is frequently en... more Purpose:Although severe, circumferential calcification of distal outflow vessels is frequently encountered, its effect on bypass graft patency rates has not been well established. Methods: Using a computerized vascular registry database, we conducted a retrospective review of 1957 bypass grafts with distal anastomoses to infrapopliteal vessels performed at a single institution between 1990 and 1995. Of these cases, 101 procedures involved outflow arteries classified by the operating surgeon as severely calcified and unclampable (requiring intraluminal occluders for vascular control), whereas in 105 cases the outflow arteries had no calcification present at the distal anastomotic site. The remaining cases had varying intermediate degrees of calcification and were not analyzed. Indication for bypass procedure was limb-threatening ischemia in 90% of severe calcification cases and in 84% of cases without calcification. Atherosclerotic risk factors were similar except for the presence of diabetes (92% vs 74%, p < 0.001), creatinine level > 2.0 m g / d l (21% vs 8%, p < 0.01), and dialysis dependency (17% vs 3%, p < 0.001), all of which were more prevalent in the severe calcification group. Infrapopliteal distal anastomotic location and type of conduit (>90% autogenous vein) were comparable between groups. Results: Primary patency, secondary patency, and foot salvage rates at 24 months were 60%, 65%, and 77% for the severe calcification group and 74%, 82%, and 93% for the no calcification group, respectively. With secondary procedures comprising 26% of cases in each group, data from the 150 primary procedures were reanalyzed separately. In this primary procedure group, 24-month primary patency, secondary patency, and foot salvage rates were 66%, 69%, and 77% for the severe calcification group and 84%, 90%, and 96% for the no calcification group, respectively. Although patency and salvage rates were consistently lower for the severe calcification group in all analyses, these differences did not achieve significance by log-rank life-table analysis at 2-year follow-up. Perioperative 30-day mortality (0.99% severe calcification vs 0.95% no calcification) and 24-month survival rates (84% severe calcification vs 83% no calcification) were also similar between groups. Conclusion: These data suggest that effective techniques exist to perform infrapopliteal bypasses to severely calcified, unclampable outflow arteries with results comparable with those obtained with clampable, tmcalcified vessels. The finding of severe, circumferential calcification of outflow target arteries should not dissuade vascular surgeons from distal bypass for limb salvage indications.
Journal of Vascular Surgery, 1995
Although the technical feasibility of pedal artery bypass for limb salvage is now well establishe... more Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability. Methods: We reviewed our experience over an 8-year period in 367 consecutive patients undergoing 384 vein bypass grafts to the dorsalis pedis for limb salvage. Results: Ninety-five percent of the patients had diabetes mellitus. Infection complicated ischemia at initial presentation in 55.2% of patients. The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent exploration for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasses were carried out in 357 of 362 cases, where preoperative arteriography demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 1i of 12 patients where angiographic status was unknown. All procedures were performed with vein: in situ 38.5%, reversed 29%, nonreversed 18%, arm vein 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a previously placed graft in 5%, and a tibial artery in 1%. There were seven perioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Twenty-nine grafts failed within 30 days (7.5%), but 19 were successfully revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional major amputations. Actuarial primary and secondary patency and limb salvage rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patient survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts. Conclusions: Dorsalis pedis arterial bypass is an effective limb salvage procedure with 10ng-term durability comparable to distal vein grafts placed into more proximal arteries.
Journal of Vascular Surgery, 1992
Journal of Vascular Surgery, 2000
Greater saphenous vein (GSV) is the preferred conduit for infrainguinal revascularization. 1-11 H... more Greater saphenous vein (GSV) is the preferred conduit for infrainguinal revascularization. 1-11 However, up to 45% of patients seen with critical lower extremity ischemia do not possess a usable ipsilateral GSV. 1,12,13 Consequently, the question of what alternative conduit should be used in the absence of an adequate ipsilateral GSV has arisen. 14 The alternative conduits may be generally divided into autogenous and non-autogenous, or prosthetic, groups. Prosthetic conduit bypass grafts to the popliteal artery have achieved moderate success. 8,15 Prosthetic grafts to the tibial vessels have also been
Journal of Vascular Surgery, 2012
Background: Percutaneous transluminal angioplasty ؎ stent (PTA/S) and surgical bypass are both ac... more Background: Percutaneous transluminal angioplasty ؎ stent (PTA/S) and surgical bypass are both accepted treatments for claudication due to superficial femoral artery (SFA) occlusive disease. However, long-term results comparing these modalities for primary intervention in patients who have had no prior intervention have not been reported. We report our results with 3-year follow-up. Methods: We reviewed all lower extremity bypass procedures at Beth Israel Deaconess Medical Center from 2001 through 2009 and all PTA/S performed from 2005 through 2009 for claudication. We excluded all limb salvage procedures and included only those that were undergoing their first intervention for claudication due to SFA disease. We recorded patient demographics, comorbidities, perioperative medications, TASC classification, and runoff. Outcomes included complications, restenosis, symptom recurrence, reinterventions, major amputation, and mortality. Results: We identified 113 bypass grafts and 105 PTA/S of femoral-popliteal lesions without prior interventions. Bypasses were above the knee in 62% (45% vein) and below the knee in 38% (100% vein). Mean age was 63 (bypass) versus 69 (PTA/S; P < .01). Mean length of stay (LOS) was 3.9 versus 1.2 days (P < .01). Bypass grafts were used less for TASC A (17% vs 40%; P < .01) and more for TASC C (36% vs 11%; P < .01) and TASC D (13% vs 3%; P < .01) lesions. There were no differences in perioperative (2% vs 0%; not significant [NS]) or 3-year mortality (9% vs 8%; NS). Wound infection was higher with bypass (16% vs 0%; P < .01). None involved grafts. Bypass showed improved freedom from restenosis (73% vs 42% at 3 years; hazard ratio [HR], 0.4; 95% confidence interval [CI], .23-.71), symptom recurrence (70% and 36% at 3 years; HR, 0.37; 95% CI, .2-.56), and freedom from symptoms at last follow-up (83% vs 49%; HR, 0.18; 95% CI, .08-.40). There was no difference in freedom from reintervention (77% vs 66% at 3 years; NS). Multivariable analysis of all patients showed that restenosis was predicted by PTA/S (HR, 2.5; 95% CI, 1.4-4.4) and TASC D (HR, 3.7; 95% CI, 3.5-9) lesions. Recurrence of symptoms was similarly predicted by PTA/S (HR, 3.0; 95% CI, 1.8-5) and TASC D lesions (HR, 3.1; 95% CI, 1.4-7). Statin use postoperatively was predictive of patency (HR, 0.6; 95% CI, .35-.97) and freedom from recurrent symptoms (HR, 0.6; 95% CI, .36-.93). Conclusions: Surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased LOS and wound infection. Statins improved freedom from restenosis and symptom recurrence overall.
Journal of Vascular Surgery, 2012
The introduction of endovascular aneurysm repair has resulted in a decline in open abdominal aort... more The introduction of endovascular aneurysm repair has resulted in a decline in open abdominal aortic aneurysm repairs performed by vascular residents. The purpose of this study was to evaluate if a similar trend has occurred with open lower extremity revascularization procedures, with increased endovascular procedures producing a decrease in the number of open lower extremity revascularizations. Furthermore, this study evaluates the effect of endovascular procedure volume on the frequency of subtypes of open lower extremity procedures performed. Methods: The total number of vascular procedures, lower extremity bypasses, and endovascular interventions from 2000 to 2010 were analyzed from case logs of vascular residents as reported by the Accreditation Council for Graduate Medical Education. Results: The average number of cases performed by vascular residents has increased by 150% from 463.9 in 2000 to 1168 in 2009, due to the increased number of endovascular procedures. The average number of endovascular revascularizations has increased by 317% from 40.5 performed in 2000 to 168.9 in 2009. Femoral-popliteal bypasses have increased in frequency by 27% whereas the number of infrapopliteal bypass has remained unchanged. The largest difference is seen in femoral endarterectomies with a 234% increase from 3.2 per resident in 2001 to 10.7 per resident in 2010. Comparison of the proportion of femoral-popliteal and tibioperoneal interventions performed by angioplasty or bypass after 2007 revealed that endovascular interventions comprise 50% of procedures in the femoral-popliteal distribution, whereas 65% of infrapopliteal interventions are still performed using open techniques. Conclusions: The number of procedures performed during vascular residency has dramatically increased over the last decade secondary to the increased number of endovascular procedures. The average vascular surgery resident's open operative experience has been stable over the last 10 years, despite the increasing endovascular case volume. Residents perform femoral endarterectomy with increasing frequency, perhaps representing an increasing volume of hybrid procedures. Gaps in information available for evaluating resident training remain a significant obstacle. Moving forward, revision of the current reporting system to a format that more accurately reflects resident experience would be beneficial.
Journal of Vascular Surgery, 2011
Debate exists as to the benefit of angioplasty vs bypass graft in the treatment of lower extremit... more Debate exists as to the benefit of angioplasty vs bypass graft in the treatment of lower extremity peripheral vascular disease. The associated costs are poorly defined in the literature. We sought to determine national estimates for the costs, utilization, and outcomes of angioplasty and bypass graft for the treatment of both claudication and limb threat. Methods: We searched the Nationwide Inpatient Sample (NIS) database (1999-2007), identifying patients who had an identifiable International Classification of Disease (ICD)-9 diagnosis code of atherosclerotic disease (claudication [440.21] or limb threat [440.22-440.24]). Of these, only patients who underwent intervention of angioplasty ؎ stent (percutaneous transluminal angioplasty [PTA; 39.50-39.90]), peripheral bypass graft (BPG; 39.29) or aortofemoral bypass (ABF; 39.25) were included. We compared demographics, costs, and comorbidities, as well as multivariableadjusted outcomes of in-hospital mortality and major amputation. Additionally, we used the New Jersey State Inpatient and Ambulatory databases in order to better understand the influence of outpatient procedures on current volume and trends. Results: There were 563,143 patients identified (PTA: 38%, BPG: 50%, ABF: 6%; 5.1%: multiple procedure codes). Patients who had PTA and BPG were similar in age (70.4 vs 69.5 years) but older than patients who had ABF (61.8 years, P < .01). Patients who underwent PTA were more often women (PTA: 46%, BPG: 42%, ABF: 45.2%; P < .01). Average costs for PTA increased over 60% for claudication between 2001 and 2007
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