Background: This randomized prospective study compared the treatment of superficial femoral artery occlusive disease percutaneously with an expanded polytetrafluoroethylene (ePTFE)/nitinol self-expanding stent graft vs surgical femoral to above knee popliteal artery bypass with synthetic graft material.Methods: One hundred limbs in 86 patients with superficial femoral artery occlusive disease were evaluated from March 2004 to May 2005. Patient symptoms included claudication and limb-threatening ischemia with or without tissue loss. Trans-Atlantic InterSociety Consensus (TASC II) A (n ϭ 18), B (n ϭ 56), C (n ϭ 11), and D (n ϭ 15) lesions were included. Patients were randomized prospectively into a percutaneous treatment group (group A; n ϭ 50) with angioplasty and placement of one or more stent grafts or a surgical treatment group (group B; n ϭ50) with a femoral to above knee popliteal artery bypass using synthetic conduit (Dacron or ePTFE). Patients were followed up for 48 months. Follow-up evaluation included clinical assessment, physical examination, ankle-brachial indices (ABI), and color flow duplex ultrasound imaging at 3, 6, 9, 12, 18, 24, 36, and 48 months. Results: Mean (standard deviation) total lesion length of the treated arterial segment in the stent graft group was 25.6 (15) cm. The stent graft group demonstrated a primary patency of 72%, 63%, 63%, and 59% with a secondary patency of 83%, 74%, 74%, and 74% at 12, 24, 36, and 48 months, respectively. The surgical femoral-popliteal group demonstrated a primary patency of 76%, 63%, 63%, and 58%, with a secondary patency of 86%, 76%, 76%, and 71% at 12, 24, 36, and 48 months, respectively. No statistical difference was found between the two groups with respect to primary (P ϭ .807) or secondary patency (P ϭ .891). A statistical difference was found in limb salvage and amputation-free survival at 48 months, however, with limb salvage rates of 98% in the stent graft group and 84% in the surgical group (P ϭ .039).Conclusions: Management of superficial femoral artery occlusive disease with percutaneous stent grafts exhibits similar primary patency at 4-year (48-month) follow-up compared with conventional femoral-popliteal artery bypass grafting with synthetic conduit. This treatment method may offer an alternative to treatment of the superficial femoral artery segment for revascularization when a prosthetic bypass is being considered or when autologous conduit is unavailable.

Retrograde open mesenteric stenting for acute mesenteric ischemia is a viable alternative to bypass.

Recent reports point to problems in the clinical assessment of the cardiopulmonary system in hemodynamically unstable patients, especially with the decreasing usage of pulmonary artery catheters. Our purpose was to evaluate the hypothesis that clinical judgment alone is inadequate for a reliable estimate of cardiopulmonary status in critically ill patients. Physician assessments (high, normal, or low) of cardiac index (CI) and thoracic fluid content (TFC) were made in 68 acute trauma cases and compared to the results obtained with impedance cardiography (ICG). Physician assessment using clinical judgment alone was correct only 42 per cent and 57 per cent, respectively, for CI and TFC. There was very little difference in heart rate (HR), blood pressure (BP), Glasgow Coma Score (GCS), and the number of injured systems between the incorrect and correct assessments of CI. However, the mean Injury Severity Score (ISS) was markedly higher for the incorrect than the correct CI values (18.8 ± 9.3 vs 14.2 ± 9.8, P = 0.0589). Thus, there is a need for an objective measurement of CI and TFC especially in the more severely injured patient. The inaccuracy of the clinical exam strongly suggests the need for a supplemental measurement, which the new and improved ICG monitor could provide.

years) and 125 women (mean age, 70.0 Ϯ 11.2 years; P ϭ NS). Women were more likely to undergo treatment for critical limb ischemia (87.7% vs 77.7%; P ϭ .028) and less likely to have treatment for claudication (12.3% vs 22.3%; P ϭ NS). Women were also more likely to undergo balloon angioplasty (57.5% vs 68.9%; P ϭ .043). However, men were more likely to have coronary disease, history of coronary bypass grafting, and chronic renal insufficiency. TransAtlantic Intersociety Consensus distribution, incidence of smoking, and diabetes were equivalent in both sexes. When adjusted for comorbidities, women had higher 24-month primary patency rates (46.0% Ϯ 6.1% vs 30.4% Ϯ 5.9%; P ϭ .016) and limb salvage rates (87.5% Ϯ 4.1% vs 82.9% Ϯ 5.4%; P ϭ .041) than men for tibial lesions with concurrent proximal disease. The difference in 24-month patency between women and men was more pronounced for isolated tibial lesions (50.1% Ϯ10.1% vs 28.8% Ϯ 10.4%; P ϭ .002). Although the overall complication rates were similar, women had comparatively higher rates of postoperative access site thrombosis than men (8.9% vs 0.6%, P ϭ .001).Conclusions: Overall, endovascular interventions below the knee are safe and effective in women and should be considered the first-line modality for the management of critical tibial occlusive disease. However, further investigation and development of technique to better fit the female anatomy is necessary to improve the gender-related disparity in access site-related complications.