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Homocysteine as a Risk Factor in Atherosclerotic Cardiovascular Disease

Strategies focused on traditional risks factors for cardiovascular disease (CVD) such as tobacco use, hypertension, hyperglycemia, lipid abnormalities, obesity, and physical inactivity have failed to stem the tide of CVD, and investigators have begun to focus on other risk factors termed by the U.S. National Academy of Clinical Biochemistry (NACB) “emergent or new risk factors.” Based on mounting evidence from observational and epidemiologic studies, the NACB…

Hypertension as a Risk Factor in Atherosclerotic Cardiovascular Disease

Hypertension is a major remediable risk factor for atherosclerotic cardiovascular disease. In serial U.S. population samples the prevalence of hypertension in adults has decreased slightly from 29.0% to 27.6% from 1999 to 2008. During that period, numerous randomized clinical trials proved that pharmacologic antihypertensive therapy decreases the risk of stroke, heart attack, and mortality. There have been encouraging trends in improving of the rates for hypertension…

Treatment of Dyslipidemia and Hypertriglyceridemia

Dyslipidemia is a major risk factor for peripheral arterial disease (PAD). Management of dyslipidemia is based on the National Cholesterol Educational Panel’s (NCEP) guidelines, initially published in 1988. These guidelines are based on a large body of evidence that demonstrates lowering low-density lipoprotein cholesterol (LDL-C) results in statistically significant reductions in cardiovascular (CV) events including those in patients with PAD. Based on these trials, guidelines include…

Smoking Cessation

Tremendous progress has been made in reducing the incidence of tobacco abuse. This is partly the result of the health care profession educating and counseling smokers, but is also undoubtedly related to the increasing inconvenience and social stigma of smoking. The rising cost of cigarettes and the increasing prohibitions against smoking in public places have clearly been shown to decrease the incidence of smoking. Although the…

Smoking as a Risk Factor in Atherosclerotic Cardiovascular Disease

Tobacco smoke is a major cause of death; it leads to an estimated 443,000 deaths per year in the United States. Cardiovascular disease accounts for a third of these smoking-associated deaths. Many decades ago, the epidemiologic association of smoking and cardiovascular disease was first recognized. Since then, a plethora of studies have supported these early findings and shown evidence for the dire consequences of exposure to…

The Metabolic Syndrome in the Modern World

In 2010, it was estimated that among all industrialized Western countries, between one in three to one in five people had the metabolic syndrome. In the United States alone that amounted to approximately 50 million to 75 million people. This population seems to be expanding at an alarming rate. It is estimated that by 2020, nearly one half of people in the United States will have…

Pulmonary Risks in Patients Being Treated for Aortic Aneurysms and Occlusive Disease

Pulmonary complications occur commonly following major vascular surgery. The spectrum of such complications has been best studied following abdominal aortic aneurysm (AAA) repair. This high incidence of pulmonary morbidity is perhaps not surprising when one considers that tobacco exposure, a major risk factor for vascular disease, is also the most significant risk factor for the development of chronic obstructive pulmonary disease (COPD). The types of pulmonary…

Coronary Artery Disease in Patients with Aortoiliac Occlusive Disease and Abdominal Aortic Aneurysm

Diseases of the abdominal aorta and aortoiliac system share many important pathophysiologic factors with coronary artery disease (CAD). Many of the risk factors that contribute to abdominal aortic aneurysms (AAA) and aortoiliac occlusive disease (AIOD), including diabetes, tobacco use, hyperlipidemia, and advanced age, are also risk factors for CAD. Accordingly, a prudent surgeon must always keep CAD in mind when treating a patient who has diseases…

Management of Chyloperitoneum and Chylothorax after Aortic Reconstruction

Chyloperitoneum and chylothorax are unusual but morbid conditions that were first recognized in the 17th century as complications of trauma. Each is caused by the formation of a fistula between the lymphatics and the peritoneal cavity or thoracic cavity, and they are both rare complications following aortic reconstruction. In 2008, Olthof and coworkers reported that of the 38 cases of chyloperitoneum following aortic reconstruction described in…

Management of Groin Lymphocele and Lymph Fistula

Groin lymphoceles and lymphocutaneous fistulas (LCFs) are rare but known complications of lower extremity vascular procedures that involve operative dissection within the femoral triangle. By definition, a lymphocele is a cystic collection of lymphatic fluid from a disrupted lymphatic channel. The presence of lymph fluid uncontained and draining from a recent operative wound is a lymphocutaneous fistula. Early reports of lymphocutaneous fistulas surfaced in the 1940s…

Drug Therapy of Erectile Dysfunction

The erectile mechanism is, in part, controlled by neural and endothelial nitric oxide (NO), which initiates the production of intracellular cyclic guanosine monophosphate (cGMP) in the smooth muscle tissue of the corpora cavernosa. The cGMP initiates a signaling cascade that results in smooth muscle relaxation and increased blood flow to the penile tissue and causes an erection. cGMP is broken down by phosphodiesterase 5 (PDE5), and…

Vasculogenic and Postoperative Neurogenic Impotence

Erectile dysfunction (ED) is defined as the “recurrent or persistent inability of the male to attain and maintain erection of the penis to permit satisfactory sexual intercourse,” according to the 1993 National Institutes of Health Consensus Development Panel on Impotence. It is important to take the patient’s satisfaction into consideration because expectations for sexual performance vary across a patient population. ED is considered to have an…

Aortic Graft–Enteric Fistula

Secondary aortoenteric fistulas (SAEFs) involve a communication between the gastrointestinal (GI) tract and a prosthetic vascular graft. Their successful management requires control of any bleeding, maintenance of adequate perfusion to the lower extremities, restoration of gastrointestinal tract continuity, and eradication of infection. The clinical status of the patient at presentation, the configuration of the involved prosthetic graft, and the arterial anatomy dictate the approach to treatment.…

In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts

Aortic graft infection is one of the most devastating complications in vascular surgery. Because of routine antibiotic prophylaxis before surgical procedures and adherence to aseptic surgical technique, the overall incidence of infection involving synthetic vascular grafts is relatively low. When infection does occur, however, the consequences can be potentially catastrophic. The reported incidence of infection involving a vascular graft varies in the literature, occurring after 0.2%…

Treatment of Aortic Graft Infection with Autologous Femoral Vein

There are no simple solutions to aortic graft infection, but a thoughtful approach to the surgical treatment of this condition minimizes the risk of major morbidity and mortality. No single operation is appropriate for all patients, so a working knowledge of the various options is critical to optimize outcomes. Graft Excision Eradication of the infection requires a combination of graft excision, wide débridement, and adjunctive antimicrobial…

Diagnosis of Aortic Graft Infection

The incidence of infection affecting a prosthetic aortic graft varies from less than 1% to about 4%, depending on whether the vascular prosthesis is entirely intrathoracic (1%–2%), is retroperitoneal (<1%), extends to the femoral level (2%–4%), or is an endovascular stent graft (<1%). Aortic graft infection poses considerable risk to the patient and remains one of the greatest challenges to the skills of the vascular surgeon.…

Femorofemoral Bypass for Aortoiliac Occlusive Disease

Femorofemoral bypass was first performed in the early 1950s as an alternative to the more direct aortofemoral bypass (AFB). Femorofemoral bypass, as with axillofemoral bypass, was initially employed primarily as a lower-risk alternative to AFB in high-risk patients with critical limb ischemia. It was quickly extended as a method to reconstruct patients with claudication, intraabdominal infection, or an otherwise hostile abdomen. As the vascular surgical experience…

Unilateral Retroperitoneal Iliofemoral Bypass

The typical patient with isolated iliac occlusive disease generally has intermittent claudication. Critical ischemia in the form of rest pain, ulceration, or gangrene is usually absent unless multilevel disease exists. There are several management options for symptomatic patients with unilateral iliac occlusive disease ranging from conservative medical management to endovascular catheter-based intervention or open operation. Treatment Algorithm for Iliac Occlusive Disease The initial approach for management…

Axillofemoral Bypass

Axillofemoral bypass (AxFB), a bypass graft from one axillary artery to one or both femoral arteries, was first performed in the early 1960s in patients at high cardiopulmonary risk for surgery as an alternative to the more direct reconstructive operation, an aortofemoral bypass (AFB). Initially, AxFBs were placed in patients with bilateral iliac artery occlusive disease, but the operation was quickly extended to reconstruction in patients…

Descending Thoracic Aorta to Femoral Bypass

The descending thoracic aorta–to–femoral artery bypass can be defined as a bypass from the aorta just proximal to the diaphragmatic hiatus with either a bifurcated or tube graft reaching the iliac or femoral arterial system. This operation was first performed in 1956 by Sauvage, who used an aortic homograft for a patient who had standard aortoiliac graft failure. In 1961, Blaisdell used the thoracofemoral bypass for…