We conclude that thoracoscopic sympathectomy is feasible, safe, and effective. Further studies are indicated to confirm its long-term benefits and to determine optimal thoracoscopic techniques.

Atherectomy physically removes plaque by cutting, pulverizing, or shaving it in atherosclerotic arteries using a mechanical, catheter-deliverable endarterectomy device. Theoretically, atherectomy offers the following advantages over percutaneous transluminal angioplasty (PTA): It shows a greater immediate success rate with less dissection and acute occlusion, treats complex lesions, and reduces the restenosis rate. This article presents the unique features of four atherectomy devices designed to meet the above challenges: Simpson AtheroCath, Transluminal Extraction Catheter (TEC), Trac-Wright Catheter, and Auth Rotablator. The results, complications, and limitations reported by clinical investigators are discussed critically and realistically. A new device, the OmniCath, under investigative trial, is presented briefly. Clinical studies evaluating the Simpson AtheroCath have reported impressively high initial success rates (ranging from 82% to 100%) but disparate intermediate patency results (ranging from 35% to 84%). Complications associated with the device include hematoma, pseudoaneurysm, and distal embolization. Clinical studies show that the device is relatively ineffective for treating diffusely diseased and long-occluded lesions. Restenosis has also been a primary constraint of the Simpson device, with reported restenosis rates ranging from 11% to 55% at 6 months. The initial technical and clinical success rates reported with the TEC atherectomy device have been promising at 79% to 92%; however, short- and mid-term follow-up results have been either lacking or disappointing, with a reported patency of 67% at 6 months and 51% at 12 months. Furthermore, the problems of restenosis and reocclusion have limited its short-term benefits. The Trac-Wright catheter has demonstrated widely disparate technical success rates (from 58% to 100%) and clinical success rates (from 33% to 80%). Patency rates reported have been suboptimal, ranging from 25% to 68% at 6 months and 25% to 45% at 12 months. Furthermore, severe complications associated with the device include perforation, dissection, and embolization. Reocclusion also limits the applicability of the device. The reported immediate success rates of 72% to 94% using the Auth Rotablator are similar to those reported for other atherectomy devices. Patencies reported at 1 and 2 years are dismal, ranging from 31% to 61% and from 12% to 18%, respectively. Significant complications are associated with the device, including thrombosis, arterial spasm, hemoglobinuria, hematoma, and embolization. Contrary to previous studies and expectations, perforations and dissections have been encountered by some investigators. Late restenosis and reocclusion are also significant limiting factors of the Auth Rotablator. Atherectomy currently has limited applications for treatment of peripheral arterial occlusive disease. The intermediate- and long-term results obtained with the atherectomy devices are worse than those reported for PTA. Furthermore, all of the atherectomy devices have faile...

The benefits of a laparoscopic approach to aortobifemoral bypass grafting in terms of financial savings and earlier rehabilitation in this patient was significant. This less-invasive procedure warrants further investigation.

The application of stents for treatment of peripheral arterial occlusive disease has gained widespread clinical use, but their safety and efficacy remain unclear. Stent technology is still evolving, and long-term follow-up data are sorely needed. Stents have had good success in providing a scaffold to maintain the intraluminal structure and patency of an artery. As such, stents appear to play a role in improving early results after failed or inadequate balloon angioplasty. However, stents do not prevent restenosis due to intimal hyperplasia. Furthermore, stents may be thrombogenic and prone to extrinsic compression in the peripheral position. Thus patency results are clearly worse in the femoral artery (47% at 3 years) than in the iliac artery (82-84% at 6-24 months). Furthermore, there is no evidence so far that stents improve long-term patency over standard balloon angioplasty without stents; and complication rates of stent procedures are generally 10%. Currently in the United States stents are approved for use in the iliac artery position. However, routine use of stents cannot be recommended until studies demonstrate that the results with stents are better than those with balloon angioplasty alone.

Laparoscopic aortofemoral bypass is technically feasible in a porcine model. Further experimental work with new instrumentation and technical refinement will make laparoscopic surgery feasible for the treatment of vascular disease in humans.