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The choice of intervention and conduit for lower extremity arterial reconstructions when the ipsilateral greater saphenous vein (GSV) is not present remains controversial. Many reconsider less optimal endovascular interventions, and others opt for use of the contralateral GSV, followed by other autogenous veins, sometimes used as composite grafts. When no autogenous conduit is available, options for revascularization include prosthetic grafts, modified biologic grafts, endovascular recanalization, or…
Surgical revascularization for lower extremity arteriosclerotic occlusive disease, manifested by critical limb ischemia (CLI) and life-limiting claudication, has been enhanced by an expanding array of conduit choices. In the absence of a perfect arterial substitute, autologous vein possesses the most of these desired arterial characteristics and remains the preferred substitute. However, in up to 25% of patients with CLI, adequate autologous vein is unavailable because of…
Options for the treatment of patients with limb-threatening lower extremity ischemia in the setting of multilevel occlusive disease are diverse. An open revascularization with the greater saphenous vein (GSV) in the setting of extensive disease or after failed endovascular approach may be most appropriate. Unfortunately, the GSV is a limited resource and is not available or of adequate quality or length to be useful in an…
Arm veins are now well established as versatile arterial conduits for infrainguinal arterial reconstruction. Although cephalic veins were demonstrated to be effective for leg revascularization in 1969, they did not receive wide application until the early 1980s. By that time it had become known that both the cephalic and basilic veins, either as single-length grafts or as part of an autogenous composite graft, had many advantages.…
Bypass to infrageniculate arteries for chronic limb-threatening ischemia continues to provide a most challenging aspect of arterial reconstruction confronting vascular surgeons today. Their length and low flow all too often exceed the functional limits of synthetic and often even of reversed vein grafts. However, the saphenous vein used in situ provides a viable, physiologically active, and, hence, antithrombotic endothelial flow surface that is ideally suited for…
The superficial femoral artery (SFA) is the infrainguinal vessel most commonly involved with severe atherosclerotic occlusive disease. Thus, it is not surprising that vascular surgeons have been reluctant to accept the concept of preferentially using an inflow site distal to the common femoral artery (CFA). the CFA might not be safe or feasible and a more distal donor site must be considered if limb salvage is…
Vein bypass grafting for lower extremity occlusive disease remains the gold standard against which new reconstructive techniques are compared. The greater saphenous vein (GSV) is the optimal conduit for the vein bypass and may be employed in either a reversed or nonreversed orientation. Patient Selection and Preoperative Evaluation The quality of the conduit used is the single greatest factor in determining the outcome of lower extremity…
A broad knowledge accumulated from our experience with duplex imaging during a variety of vascular interventions supports a number of its valuable and unique features, including visualization of the vessel wall, substantial (up to five times) vascular magnification, precise measurements, real-time imaging in spite of limb motion, visualization of the arteries regardless of their patency, and a readily obtainable variety of hemodynamic parameters such as flow…
Endovascular therapy has evolved into an attractive first-line therapy for patients with peripheral arterial occlusive disease. Plaque excision techniques, such as atherectomy and laser ablation, attempt to improve primary patency as a standalone procedure or in conjunction with balloon angioplasty. Ideally, plaque debulking would minimize arterial wall trauma and recoil after angioplasty, thereby reducing the need for stent deployment. Cryoplasty attempts to achieve these results by…
The poor early results and marginal long-term durability of percutaneous transluminal angioplasty in the femoropopliteal segment has prompted growing interest in covered stents in the treatment of occlusive disease. The potential advantages of a minimally invasive internal bypass are significant. The diffusely diseased, highly irregular surface of the superficial femoral artery or popliteal artery is excluded in the process. Most of available clinical data regard the…
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Medical therapy is essential in management of any patient with peripheral arterial disease, regardless of the extent of disease, symptoms, or plans for intervention. Physician-supervised walking programs have been shown to improve symptoms and quality of life in patients with claudication. A meta-analysis of superficial femoral artery (SFA) angioplasty versus exercise therapy in patients with intermittent claudication found similar 3- and 6-month quality-of-life outcomes but improved…
After confirmation of peripheral arterial disease (PAD) by physical examination and Doppler ankle-to-brachial indices (ABIs), further radiologic testing, such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), or intraarterial angiogram, may be performed to further localize and potentially treat the culprit lesion. These imaging studies should be done with the goal of proceeding with treatment. Patient Selection for Treatment and Therapeutic Options Treatment options for…
Intravascular ultrasound (IVUS) imaging continues to develop and provides an important perspective of cardiovascular disease. High-resolution transmural images of the vessel allow real-time investigation of pathology and the effects of interventions. The thrust of current IVUS development is to incorporate it as an adjunct to coronary, aortic, and peripheral procedures, providing vessel wall morphometry, endovascular device guidance, and accurate assessment of the intervention. Intravascular Ultrasound Imaging…
The preferred noninvasive test for evaluating patients with suspected chronic lower extremity ischemia depends upon individual circumstances. Doppler-derived ankle-to-brachial systolic blood pressure indices (ABIs) provide an accurate and reproducible measure of overall blood supply to the foot in patients without extensive mural calcification, but they do not define the location of the occlusive disease. Four-cuff segmental blood pressures can grossly localize hemodynamically significant lower extremity arterial…
The measurement of lower extremity systolic pressure is by far the most widely used parameter for evaluating peripheral arterial disease. It is an easy measurement to perform with minimal testing equipment, it is a reliable and reproducible indicator of hemodynamically significant obstructive disease, and, unlike waveform analysis, it provides objective quantitative data. From Hales’s successful but very invasive measurement of mean arterial pressure in 1733, the…
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Complementary and alternative medicine (CAM) use is on the increase in America. The prevalence of CAM use among people with a diagnosis of cardiovascular disease (CVD) or with risk factors for such is significantly higher than in the general population. Patients who undergo cardiac surgery have been reported as using a number of CAM modalities including vitamins (54%), prayer (36%), nutritional approaches (17%), meditation (11%), massage…
Endothelial dysfunction is a key component in the pathophysiology of cardiovascular disease (CVD) and is associated with classic CVD risk factors such as dyslipidemia, hypertension, metabolic syndrome, and diabetes. Moreover, endothelial dysfunction is one of the first clinically detectable alterations in the development of atherosclerosis, and it is a common mechanistic link between atherosclerosis risk factors and the development of the disease. The vascular endothelium, far…