Annals of Vascular Surgery

Management of Complex Patients with Budd–Chiari Syndrome

2009-11-09

Therapy for patients with Budd–Chiari syndrome is well established. For those with commonly seen localized lesions, percutaneous transluminal angioplasty or stenting is the first-line treatment. Treatment methods for severely ill patients in whom intervention has failed, or those in a poor general condition, are worth exploring. From February 2002 to July 2008, 31 patients were referred to us. Eighteen patients had a failed intervention, 4 had undergone surgery, and 10 had conservative therapy. All had intractable ascites or/and hematemesis. The procedures carried out in this series included mesocavoatrial shunt in 10 patients, radical correction in 9, mesocavojugular shunt in 7 (including 2 mesojugular shunts), mesocaval shunt in 2, cavoatrial shunt in 2 (including a revision of cavoatrial shunt), and cavojugular shunt in 1. Surgical mortality and postoperative complications were both 3.2%. Twenty-eight patients had a mean follow-up of 40 months. Outcome of follow-up was measured as excellent, good, fair, poor, and death (28.6%, 53.6%, 10.7%, 3.6%, and 3.6%, respectively). The total mortality of the group is 6.5%. After appropriate preoperative evaluation and preparation, active and cautious treatment individualized to the underlying disease may help severely ill patients with Budd–Chiari syndrome.

Prehospital Treatment of Infrarenal Ruptured Abdominal Aortic Aneurysms: A Multicentric Analysis

2010-01-05

Background: The aim of this study was to evaluate the quality of the current treatment of patients presenting with ruptured abdominal aortic aneurysms (RAAAs), from the first symptoms to the operating room with an analysis of preoperative mortality risk factors.Methods: For 3 years, in four vascular surgery departments, we have collected all the consecutive cases of patients operated on for RAAA. We analyzed the initial clinical situation, the means of transportation, the time elapsed before treatment, and the mortality rate at 3 days. Sixty-six RAAAs were operated on. Mean patient age was 76 years (range, 52–93 years).Results: The initial symptoms were a precisely located pain either abdominal (45.3%), lumbar (17.2%), or both (14.1%) or feeling faint (10.9%). In 22.7% of the cases, an initial hemodynamic instability was observed. In 46.8% of the cases, patients first went to a peripheral hospital before being admitted into a referral centre. In 84.5% of the cases, medical mean of transportation was used. The mean distance covered was 59.8 kilometers (range, <5 km to 213 km). The initial diagnosis was accurate in 67.3% of the cases. The mean intrahospital waiting period between the arrival at a reference center and the admission into an operating room was 127minutes. Global mortality rate was 44.2%. The main preoperative mortality factor to be noticed was the initial hemodynamic instability (p=0.0031). Among stable patients, only two of them (5.4%) worsened during the preoperative treatment.Conclusion: In our study, hemodynamic instability corresponds to the main prognosis factor of mortality. In most cases, the initial stability persisted and allowed additional evaluation. However, the intrahospital waiting periods appeared to be too long. To be optimal, the adequate treatment should be specifically designed as soon as a diagnosis has been established.

A New Preoperative Predictor of Outcome in Ruptured Abdominal Aortic Aneurysms: The Time Before Shock (TBS)

2009-11-09

Background: In patients with ruptured abdominal aortic aneurysm (RAAA) and shock, the time lag between the onset of the symptoms due to RAAA and the presence of a full developed shock syndrome was evaluated to assess its prognostic meaning. This time lag was called time before shock (TBS).Methods: Ninety-four patients operated on between 2002 and 2007 have been retrospectively analyzed regarding TBS and the following parameters: presence of shock, severity of bleeding, age, comorbidities, and gender. According to TBS, on a 10-hour cutoff value, three groups of patients were distinguished: patients with TBS of 10 or less (short TBS), patients with TBS greater than 10 (long TBS), and patients without shock. The relationship of these variables with intraoperative and 30-day mortality was analyzed by both univariate and multivariate analyses.Results: In the univariate analysis, patients with short TBS presented with four-fold mortality compared to patients without shock (p=0.000), whereas the increase in mortality of the patients with long TBS was nonsignificant (p=0.448). The mortality in patients with shock (presence of shock) was 3.7 times higher than in patients without shock (p=0.001). The mortality related to massive bleeding was 3.7 times higher than that associated with moderate bleeding (p=0.001). An increased mortality with borderline significance level was observed in patients older than 75 years (p=0.052). The relationship of mortality to the presence of comorbidities and gender was not significant. In the multivariate analysis, the mortality among the patients with short TBS was clearly highest, after either massive or moderate bleeding. In the logistic model with TBS, the Wald test showed as significant both short TBS (p=0.001) and severity of bleeding (p=0.033) but not age (p=0.103) and long TBS (p=0.0401). The model with TBS presented a better performance than that with shock, showing higher sensitivity, higher values of Youden's J, and a greater proportion of the total variation in mortality. Through the model with TBS, two groups of patients (those 75 years or younger with massive bleeding and those older than 75 years with moderate bleeding), both with short TBS, presented with a high risk of death not predicted by the model with shock.Conclusion: TBS seems to complete the information given by the parameter “presence of shock,” and its evaluation allows a more effective judgment of the risk of death, at emergency admission of patients with RAAA.

Retroperitoneal Approach to Abdominal Aortic Aneurysm Repair Preserves Splanchnic Perfusion as Measured by Gastric Tonometry

2009-09-11

Background: We investigated if minimizing bowel manipulation and mesenteric traction using the retroperitoneal approach in open abdominal aortic aneurysm (AAA) repair preserves splanchnic perfusion, as measured by gastric tonometry, and reduces the systemic inflammatory response and dysfunction of the various organs.Methods: Patients undergoing elective AAA repair were randomized into three groups. Group I had repair via the retroperitoneal approach, while groups II and III were repaired via the transperitoneal approach with the bowel packed within the peritoneal cavity or exteriorized in a bowel bag, respectively. A tonometer was used to measure gastric intramucosal pH (pHi), as an indicator of splanchnic perfusion, just prior to aortic clamping, during clamping, and at 0.5, 1, 2, 4, 6, and 12hr after clamp release. Multiorgan dysfunction syndrome (MODS) and systemic inflammatory response syndrome (SIRS) scores were calculated and systemic interleukins (IL-6 and IL-10) measured at predetermined intervals.Results: Thirty-four patients were successfully randomized. The gastric pHi was significantly lower in group II (n=12) and group III (n=11) compared to group I (n=11) during aortic clamping and immediately after clamp release (p<0.05). The aortic clamp time, blood loss, MODS and SIRS scores, and systemic cytokine response were similar in all three groups. When the three groups were combined, there were significant positive correlations between the operation time, aortic clamp time, and amount of blood lost and transfused with plasma IL-6 levels and MODS score on the first postoperative day.Conclusion: The retroperitoneal approach for open AAA repair is associated with gastric tonometric evidence of better splanchnic perfusion compared to the transperitoneal approach.

Femoral Artery Complications after Cardiac Catheterization: A Study of Patient Profile

2009-09-11

Background: Femoral artery complications after cardiac catheterization range from simple events to severe complications requiring invasive techniques or surgery with significant economic costs. This study evaluated early femoral arterial complications from percutaneous arterial access during diagnostic and interventional cardiac catheterizations in an era of widespread use of closure devices and intense anticoagulation.Methods: Patients undergoing percutaneous cardiac catheterization via the femoral artery between August 2005 and December 2005 were identified using an ICD-9 patient database. Forty-six data points were extracted by retrospective chart review, including demographics, comorbidities, type of anticoagulation, procedural details, and postprocedural complications. Univariable analysis and binary logistic regression were used to determine factors associated with complications.Results: Eighty-two of 579 patients (14%) suffered complications. The most common complications were hematomas (51 patients, 10%) and active bleeding (14 patients, 2.4%). Closure devices were used in 470 patients. After multivariable correction, use of preprocedural (odds ratio [OR]=5.65, 95% confidence interval [CI] 2.58-12.3, p<0.001) and intraprocedural (OR=4.88, 95% CI 1.95-12.3, p<0.001) antithrombotic agents (antiplatelet and/or anticoagulants), intraprocedural clopidogrel (OR=2.98, 95% CI 1.21-7.30, p=0.017), and postprocedural heparin (OR=29.4, 95% CI 3.56-250, p=0.002) were associated with increased risk. Coronary artery disease was associated with increased risk (OR=11.1, 95% CI 4.78-25.6, p<0.001), while use of a closure device (OR=0.263, 95% CI 0.125-0.553, p<0.001), male gender (OR=0.421, 95% CI 0.220-0.805, p=0.009), and prior catheterization (OR=0.033, 95% CI 0.012-0.095, p<0.001) were protective.Conclusion: With increasing numbers of complex coronary endovascular procedures and widespread use of high-dose multidrug antithrombotic therapy, femoral artery injuries will continue to be a significant risk for patients. Postprocedural monitoring with a high level of suspicion and use of vascular closure devices in high-risk patients may decrease the incidence of femoral artery complications. The use of vascular closure devices after low-risk procedures in male patients or those with previous ipsilateral catheterization might not be warranted but needs further study.

Vertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study

2009-12-04

Background: To look at wound complications with either a transverse or vertical groin incision in vascular surgery.Methods: All patients undergoing vascular procedure requiring access to femoral vessels were randomized to either a vertical or transverse incision. Patients were followed up for 28 days after the procedure and examined for wound infection, wound breakdown, development of lymphatic leak and lymphatic collection.Results: 88 patients (116 groins) were randomised to either incision. Of these, 55 groins had transverse incisions and the remaining had vertical incisions. There was no significant difference in the patient's age, sex, smoking, diabetes, operative times and use of prosthetic material. 29/61 (47.5%) of vertical incisions and 7/55 (12.7%) of transverse incisions had wound complications (p<0.001). There were 13(11%) wound infections in the 116 groins by day 28. There were 3 wound infections in the transverse group and 10 infections in the vertical group (p=0.062). There were 17 (27.9%) lymphatic leaks in the vertical incisions compared to 7(12.7%) in the transverse incisions (p=0.044). The majority of infections were diagnosed after patient discharge from hospital.Conclusion: Wound complications are higher with vertical incision. Many infections are diagnosed after patient discharge. We recommend transverse incisions for access to the femoral vessels in the groin.

Eligibility for Endovascular Technique and Results of the Surgical Approach to Popliteal Artery Aneurysms at a Single Center

2009-12-25

Background: Less than 0.1% of the population experiences a popliteal aneurysm (PA), and the consequences of not treating PA include a significant risk of embolization, thrombosis, and limb loss. Surgical treatment for this vascular disease has produced excellent clinical results, but there remain an increasing number of published reports that continue to question the efficacy of endovascular therapies.Methods: All consecutive patients operated on for PA at our hospital in the years 2000–2007 were reviewed retrospectively for clinicopathological data and applicability for endovascular treatment.Results: Forty-six patients were surgically treated for 56 PAs (42 vein, 11 alloplastic material, and one composite graft). Overall survival rates after 2 and 5 years were 77% and 54%, respectively. Reintervention-free survival rates at 2 and 5 years were 71% and 43%, respectively. Graft patency for veins was significantly higher, with a hazard ratio of 0.025 (95% confidence interval 0.002–0.304, p = 0.004). Twenty-two of the 37 patients (59.5%) with a sufficient angiograph appeared to be eligible for endovascular treatment.Conclusion: Despite the positive results of surgical repair shown in our study and in the existing literature, endovascular treatment has a high technical eligibility with good reported outcomes and represents an alternative for open surgery.

The Impact of Isolated Tibial Disease on Outcomes in the Critical Limb Ischemic Population

2010-01-04

Background: Most patients with critical limb ischemia (CLI) have multilevel infrainguinal peripheral arterial disease (M-PAD). One-third of CLI patients will have isolated tibial disease (ITD). The treatments for multilevel disease or ITD differ depending on whether open or endovascular procedures are used, but we questioned whether outcomes from these procedures differ. We evaluated outcomes of CLI patients after open and/or endovascular revascularization for CLI and assessed the impact of disease distribution.Methods: Four hundred forty-six CLI patients (Rutherford 4-6) who underwent revascularization from 2001 to 2005 were evaluated arteriographically and followed after revascularization with noninvasive testing. Based on arteriographic data, all patients with ITD (occlusions in one or more tibial arteries) were compared with patients with occlusive femoropopliteal disease with or without concomitant tibial occlusions (M-PAD). Patients with disease solely above the inguinal ligament were excluded. Clinical data (survival, amputation-free survival, primary patency, secondary patency, limb salvage, maintenance of ambulation, and maintenance of living status) were acquired from a prospective vascular database, allowing the comparison of revascularization outcomes according to disease distribution.Results: In this study, 36% of patients had ITD and 64% presented with M-PAD. The severity of ischemia at presentation was rest pain (28.5%), ulceration (42.3%), and gangrene (29.1%). In this study, 92% presented exclusively with infrainguinal disease, and 8% presented with both suprainguinal and infrainguinal disease. Risk factors included diabetes mellitus (61.2%), smoking (61.0%), coronary artery disease (57.9%), hypertension (84.3%), hyperlipidemia (40.4%), obesity (15.5%), and chronic obstructive pulmonary disease (19.3%). In comparing the ITD and M-PAD groups, there was no difference in primary patency at 2 years. All other outcomes were statistically different out to 3 years including survival (50.4% vs. 62.6%; p = 0.0026, hazard ratio [HR] 0.669); amputation-free survival (35.1% vs. 50.2%; p = 0.0062; HR 0.595); limb salvage (65.2% vs. 74.4%; p = 0.0062; HR 0.595); maintenance of ambulation (68.9% vs. 76.9%; p = 0.0352; HR 0.644); maintenance of living status (79.0% vs. 84.8%; p = 0.0403; HR 0.599); and secondary patency (66.8% vs. 74.8%; p = 0.0309; HR 0.665). Multivariate analyses reveal that ITD is not an independent predictor of outcome after controlling for confounding factors, of which tissue loss and end-stage renal disease correlate most consistently with poor clinical outcomes.Conclusion: After revascularization for CLI, ITD carries a worse prognosis (amputation-free survival, limb salvage, survival, maintenance of ambulation, and independent living status) compared with patients with M-PAD, despite the “greater” disease burden in M-PAD patients. ITD patients are more likely to have confounding factors such as diabetes mellitus, renal disease, and worse ischemia at presentation than those with M-PAD. The recognition of ITD may be helpful in identifying high-risk patients but is not an independent risk factor for poor outcomes.

Radiofrequency-Powered Segmental Thermal Obliteration Carried out with the ClosureFast Procedure: Results at 1 Year

2010-01-28

This prospective and multicenter study shows the results at 1 year of radiofrequency-powered segmental thermal obliteration (RSTO) carried out with the ClosureFast® procedure. The RSTO clinical and duplex ultrasound imaging results were evaluated at 3 days, 3 months, 6 months, and 1 year. All procedures were carried out on outpatients under tumescent local anesthesia. Among the 295 members who were treated, 289 were reexamined at 3 days, 290 at 3 months, 289 at 6 months, and 220 at 1 year. Occlusion scores were 99.7%, 99.3%, 98.6%, and 96.9% at, respectively, 3 days, 3 months, 6 months, and 1 year. At 3cm below the saphenofemoral junction, before the procedure, the greater saphenous vein (GSV) diameter was 5.4±2mm (range 2-18). It decreased to 4.5±1.7mm at 3 days, 2.4±1.5mm at 6 months, and 1.3±0.9mm at 1 year. In members reexamined at 1 year, the decrease in diameter of the treated vein compared with the preprocedural measurement was 79% (p<0.001, t-test). At 1 year, in 58% of the cases, duplex ultrasound imaging at mid-thigh level could not show the GSV trunk. Preprocedural pain that was present in 57.5% of the cases decreased to 10.8% of the cases at 3 days and 2% of the cases at 1 year (p<0.001, χ2 test). Among the treated limbs, 70.1% did not present with any postprocedural pain at any time of the follow-up. On the third day, the patients evaluated the mean pain intensity at 0.7±1.6 on a visual analog scale of 0–10. During the follow-up, no painful indurations were noticed in 67.7% of the legs. No thromboembolic complications were reported. Paresthesias were observed in 3.4% of the cases. Invalidity clinical score, evaluated at 3.9±2 before the procedure, decreased to 3.5±1.2 on the third day, 0.9±1.5 at 3 months, 0.7±1.2 at 6 months, and 0.5±1.1 at 1 year. This study confirms the efficacy of RSTO when using ClosureFast, which allows obliteration of the GSV trunk in 97% of cases at 1 year with few side effects and almost no postprocedural pain.

Intraoperative Adjunctive Stem Cell Treatment in Patients with Critical Limb Ischemia Using a Novel Point-of-Care Device

R. Kolvenbach, Carla Kreissig, Catherine Cagiannos, Rana Afifi, Eva Schmaltz — 2009-11-06

Introduction: In a prospective trial we tested whether adjunctive intraoperative stem cell treatment in patients with critical limb ischemia (CLI) can be performed safely in combination with bypass surgery and/or interventional treatment. The end point of our study was the safety and integrity of a novel point-of-care system used in patients with CLI.Methods: We included only patients with CLI and tissue loss according to Rutherford categories 4-6. The Harvest Bone Marrow Aspirate Concentrate System consists of an automated, microprocessor-controlled dedicated centrifuge with decanting capability and the accessory BMAC Pack for processing a patient's bone marrow aspirate (BMA). The centrifuge is portable and enables BMA to be rapidly processed in the operating room to provide an autologous concentrate of nucleated cells for immediate injection. The surgeon aspirated 120 ml BMA from the iliac crest.Results: Eight consecutive patients were treated according to the study protocol. The mean follow-up period was 9.2 months (range 2-18). Stem cells were always injected during the final revascularization attempt. One minor amputation and two major amputations were required. In five of eight patients there was a discrete increase in the ankle-brachial index post–stem cell treatment. The dose of stem cells after centrifugation was 17.2 (range 13.8-54.2)×10E6 CD34-positive cells and 7.8 (range 1.8-35.9)×10E6 CD133-positive cells. The injected dose of VEGFR-2-coexpressing stem cells was 0.5-5.7×10E4.Conclusion: We were able to show that the buffy coat preparation using a point-of-care system is a simple and fast method to enrich stem cells from BMAs. This automated system gives high recovery rates and good reproducibility.

Combined Distal Venous Arterialization and Free Flap for Patients with Extensive Tissue Loss

2009-09-17

Background: We evaluated the mid-term outcome of distal venous arterialization (DVA) and the role of a combined free flap as a bridgehead for blood supply.Methods: In the past 5 years, nine patients with extensive tissue loss and lacking graftable distal arteries underwent DVA. These consisted of four primary DVAs, three combined DVA and free flap procedures, and two adjuvant DVAs for hemodynamically failed distal bypasses. After nine primary DVAs, three redo DVAs were performed for early failure. Etiologies were four Buerger disease and five arteriosclerosis obliterans, including three dialysis patients.Results: Among the nine DVA cases, there were five primary failures: two underwent amputation, two had successful redo DVA, and the remaining one did not require redo DVA. Primary patency, secondary patency, and limb salvage rates were 44.4%, 55.6%, and 77.8%, respectively. The postoperative period was 1–36 months (median 12). Angiography demonstrated DVA was effective in the early period, and development of collaterals or a capillary network from the free flap replaced the DVA function in the intermediate period.Conclusion: DVA can be effective as a procedure for limb salvage in patients without graftable distal arteries, and a combined free flap is effective and functions as a bridgehead for blood supply to the ischemic zone.

Implementation and Efficacy of Selective Sonographic Screening for Carotid Disease before Cardiac Surgery

2010-01-25

Background: Preoperative carotid sonography with consecutive preventive strategies might reduce stroke risk during cardiac surgery. Since routine sonography in all patients may be unfeasible, an approach to examine preselected patients was investigated.Methods: A prognostic model predicting carotid disease was developed using the clinical data of 1,768 routinely examined patients. It recommended 1,018 of 4,814 patients of a following collective for selective sonography. Patients recommended for preoperative sonography were compared to those selected in clinical practice.Results: Besides the evaluated predictor variables, a history of syncope/cardiogenic shock and of pulmonary disease was associated with patient selection for sonography in clinical practice, even though both variables were not associated with severe carotid disease. In patients who underwent sonography, although this was not recommended by the prognostic model, severe carotid disease was estimated lower than what was actually detected, suggesting a change in relative relevance of predicting variables along with the change in frequencies of patients' cardiovascular characteristics.Conclusion: Prognostic models for selective screening before cardiac surgery may require reevaluation over time, especially when baseline characteristics used for prediction have changed. Criteria used in clinical practice to select patients for screening may differ from those recommended by investigational studies.

The Impact of a Systemwide Policy for Emergent Off-Hours Venous Duplex Ultrasound Studies

2009-09-11

Background: We evaluated the impact of an after-hours policy regulating venous duplex ultrasound (VDU) for deep vein thrombosis (DVT) diagnosis on resource utilization and patient care.Methods: On July 1, 2007, we altered the approach to emergent VDU of patients with potential DVT during off-hours (defined as 5:00p.m. to 7:00 a.m. weekdays, after 3:30p.m. Saturdays and Sundays). Instead of 24hr access, we permitted a venous duplex study in the noninvasive vascular laboratory (NIVL) only after meeting set criteria developed collaboratively across services. In the emergency department (ED), we based all VDU requests on a preset modified Wells score (MWS) as determined by the ED physician. Those patients with MWS 0 or 1 and those above 1 who could receive empiric single-dose low–molecular weight heparin (LMWH) received next-morning imaging unless consultation with a vascular surgeon created an emergent imaging plan. In parallel, inpatient emergent VDU was permitted only after contact with an attending vascular surgeon and where empiric short-term anticoagulation could not occur safely. We tracked NIVL utilization, patient morbidity, sonographer retention, and satisfaction.Results: The number of overall off-hours emergent VDUs decreased from 59 to 19/month after implementation. Testing was deferred in 52 ED patients: 15 stayed in the ED for testing in the morning and 37 were discharged to be tested the following day. Thirty-one of 37 patients returned for testing as outpatient follow-up. Twenty-eight received ED LMWH while awaiting testing. No adverse events were noted with the delay. The mean MWS for ED after-hours studies was 2.9±1.6 and that for deferred ER studies was 2.4±1.3 (p=0.005). Incidentally, overall off-hours inpatient and ED VDU requests decreased 64% with no clinical adverse events in the first year. The rate of overall positive studies done off-hours increased from 6.7% to 20% (p<0.0001). Sonographer satisfaction was maintained with regulation of call.Conclusion: Our collaborative approach allowed off-hour VDU utilization to decrease without any measurable negative care impact.

Bispectral Index Changes in Carotid Surgery

2009-11-24

Background: Intraoperative monitoring of cerebral ischemia with shunting during carotid endarterectomy (CEA) remains controversial. Our objective was to evaluate the sensitivity and specificity of BIS changes during carotid clamping in relation to shunted patients in awake CEA.Methods: Eighty CEAs under cervical block were included. There were two patient groups: with clinical signs of cerebral ischemia (shunted patients) and without signs of cerebral ischemia (nonshunted patients). Data were based on bispectral index (BIS) values and neurological monitoring at different surgery time points, with special attention paid during carotid clamping. BIS values were compared between shunted and nonshunted patients. Sensitivity and specificity, along with positive and negative predictive values of a percentage BIS value decrease during carotid clamping from baseline BIS values, were calculated in both patient groups.Results: Shunting was performed in 11 patients with cerebral ischemia at carotid clamping. Mean BIS values were 82.82±11.98 in shunted patients and 92.31±5.42 in nonshunted patients at carotid clamping (p<0.001). Relative decreased BIS values in relation to basal BIS values were 13.57% in shunted patients and 3.68% in nonshunted patients (p<0.05). The percentage decrease in BIS was 14%, sensitivity was 81.8% (95% CI 49.9-96.8), and specificity was 89.7% (95% CI 79.3-95.4).Conclusion: BIS monitoring during carotid clamping is an easy, noninvasive method which correlates with cerebral ischemia in patients undergoing CEA. A decrease ≥14% from the basal BIS value presents a high negative predictive value, and ischemia is unlikely without a decrease. Nonetheless, a decrease may not always indicate cerebral ischemia with a low positive predictive value.

The Effectiveness and Feasibility of Endovascular Coil Embolization for Very Small Cerebral Aneurysms: Mid- and Long-Term Follow-Up

2009-12-25

Background: Endovascular embolization for very small cerebral aneurysms (VSCAs) is still controversial. We report our experience with endovascular coil embolization for these lesions and assess the feasibility and effectiveness.Methods: We conducted a review of our experience with endovascular treatment of a series of 19 patients with 20 VSCAs, located at the supraclinoid segment of the internal cranial artery (ICA) in seven, the cavernous ICA segment in three, the anterior communicating artery in five, vertebral artery–posterior inferior cerebellar artery in two, bifurcation of the middle cerebral artery in one, the pericallosal artery in one, and the P2 segment in one. The World Federation of Neurosurgical Societies classification before treatment was grade I in 14 patients and grade II in five patients. The strategy of endovascular treatment included coil occlusion, balloon-assisted coiling, and stent-assisted coiling. Occlusion rate was divided into (1) total/near total, occlusion rate 95-100%; (2) subtotal, occlusion rate 80-95%; and (3) partial, occlusion rate <80%. Clinical outcome of patients with ruptured aneurysm was ascertained according to the Glasgow Outcomes Scale.Results: All patients were successfully treated with coil embolization; immediate angiography determined occlusion of the aneurysm, including total occlusion in five, subtotal occlusion in nine, and partial occlusion in six. During 1-2 years of follow-up, all aneurysms were confirmed as complete occlusion by control angiography. No recurrence or coil compaction occurred. No rehemorrhage or ischemic stroke occurred.Conclusion: Endovascular coil embolization for VSCAs is effective and feasible. Initial subtotal or partial aneurysm occlusion might progress to total occlusion.

Analysis of Calcifications in Patients with Coral Reef Aorta

2010-02-08

Background: Coral reef aorta is a rare vascular disease with intraluminal calcifications of the dorsal part of the visceral aorta. The pathogenesis of this disease with its topographic and morphologic characteristics is unknown. The aim of our study was to investigate calcification inhibitors and the ultrastructure of calcifications in patients with coral reef aorta.Methods: Ten patients with coral reef aorta were examined. Calcified specimens were investigated by immunohistochemical techniques for the expression of the calcification inhibitors matrix gla protein (MGP) and fetuin-A. Vessel walls were also assessed by electron microscopic techniques including electron energy-lost spectroscopy, electron dispersive spectroscopy, and electron diffraction. Sera of patients were analyzed for fetuin-A, uncarboxylated MGP (ucMGP), and osteoprotegerin.Results: As assessed by immunohistochemistry, most MGP was detected in the vicinity of calcified regions. Serum levels of the calcification inhibitors ucMGP, fetuin-A, and osteoprotegerin were 370±107 nmol/L, 0.57±0.03g/L, and 5.64±0.79 pmol/L, respectively. Ultrastructural analysis of calcified specimens showed a core-shell structure with multiple calcification nuclei. Calcifications displayed a fine-crystalline character, and elemental analysis revealed hydroxyl apatite as the chemical compound.Conclusion: The coral reef aorta represents an extreme exophytic growth of vascular calcification with multiple nuclei which resemble typical media calcification. Positive vascular immunostaining and low serum levels of both fetuin-A and ucMGP suggest a pathophysiologic role of these calcification inhibitors in the development of coral reef aorta.

Duplication of Superficial Femoral Artery: An Uncommon Variation of the Lower Limb Arterial System

2009-12-25

The most common anatomical variation of the superficial femoral artery (SFA) is hypoplasia or aplasia, associated with persistent sciatic artery. Duplication of SFA remains uncommon. We report a case of SFA duplication discovered on an angiogram performed for critical limb ischemia, in an 80-year-old man.

Acute Mesenteric and Aortic Thrombosis Associated With Antithrombin Deficiency: A Rare Occurrence

Domenico Calcaterra, Jeremiah T. Martin, Antoine M. Ferneini, Ralph W. De Natale — 2009-11-24

Antithrombin is a potent inhibitor of the coagulation cascade exerting its primary effects on activated factors X, IX and II. It is the mechanism by which heparin and low-molecular weight heparin cause anti-coagulation. Deficiency of Antithrombin presents as a hypercoagulable state, and may result in unexplained deep venous thrombosis, arterial thrombosis and systemic embolization.

Congenital Absence of the Left Internal Carotid Artery

2009-11-24

The absence of the internal carotid artery (ICA) is a rare congenital anomaly, occurring in <0.01% of the population. Aplasia of the ICA may be harmless; however, the significance of ICA aplasia may be associated with conditions of clinical importance, such as in the setting of surgery, thromboembolic disease, and detection of cerebral aneurysms, and therefore should prompt further evaluation to rule out abnormalities. We present a case of left ICA aplasia diagnosed after work-up of neurological events. The incidence of intracranial aneurysm in association with aplasia has been reported as 25–43% compared to 2–4% in the general population. Mechanisms to explain the association between aplasia and intracranial aneurysms include embryological development or hemodynamic derangement. Recognition of this anomaly becomes important in thromboembolic disease as emboli in one cerebral hemisphere may be explained by atherosclerotic disease in the contralateral common carotid artery or vertebrobasilar system. Of significance, planning endarterectomy denotes consideration as both cerebral hemispheres may be dependent upon the atheromatous carotid. Recognizing this anomaly is important and may help prevent false diagnosis of carotid dissections or high-grade carotid stenosis.

Endovenous Therapy for the Treatment of Congenital Venous Malformations

Onur Berber, Peter Holt, Robert Hinchliffe, Matthew Thompson, Ian Loftus — 2009-11-24

The treatment of a congenital venous malformation using endovenous radiofrequency ablation in a patient is described. The patient initially underwent two treatments of foam sclerotherapy with moderate success. Later the main feeding vessel of the venous malformation became evident on examination with venous duplex and was identified as the great saphenous vein. At this point, endovenous radiofrequency ablation was used to ablate the feeding vessel and successfully treat the lesion. The procedure proceeded without complications, and the patient made a good recovery. It is recommended that patients presenting with such malformations be considered for endovenous therapy as early as possible.

Redo Arch Aneurysm Repair for New-Onset Aortic Arch Dissection Following Ascending Aortic Surgery: Long Elephant Trunk Technique Combined With Trifurcate-Branched Graft

2010-01-05

Reoperative surgical intervention for a new-onset aortic arch dissection following a Bentall procedure or graft replacement for the ascending aorta is often difficult, especially in elderly patients. Herein, we report a re-do arch replacement method using a trifurcate-branched graft and long elephant trunk anastomosis at the composite root graft on the ascending aorta. The present technique is feasible as an alternative for new-onset or residual aortic arch aneurysm, as well as dissection following an operation for the ascending aorta.

The Use of the Amplatzer Plug to Treat Dysphagia Lusoria Caused by an Aberrant Right Subclavian Artery

2009-12-10

Emerging technology with endovascular techniques has expanded our armamentarium to treat the aberrant right subclavian artery. We describe a hybrid technique using an Amplatzer plug in combination with a carotid subclavian bypass to treat a patient with dysphagia lusoria.

Endovascular Treatment of Massive Thoracic Aortic Thrombus and Associated Ruptured Atheroma

Patrick S. Wolf, H.E. Guy Burman, Benjamin W. Starnes — 2009-12-25

Atheroembolic disease typically presents with isolated lower extremity digital ischemia. Treatment traditionally includes optimization of medical management, with open surgery reserved for complicated or recurrent embolic events. We present a novel endovascular approach for treatment of complicated thoracic aortic atherosclerotic disease incidentally discovered in a 63-year-old female. The patient demonstrated visceral artery embolization from a mobile 2.6 cm atherosclerotic plaque despite maximal medical therapy. Thoracic aortic stent graft placement successfully excluded the atheroma and prevented further embolization. This case demonstrates a unique treatment option for complicated thoracic aortic atheroembolic disease utilizing a minimally invasive endovascular approach.

Mycotic Splenic Artery Aneurysm Secondary to Coxiella burnetii Endocarditis

C. Antonopoulos, M. Karagianni, N. Galanakis, C. Vagianos — 2009-12-25

Mycotic artery aneurysms are rare but potentially lethal vascular lesions due to their high risk of rupture. Bacterial endocarditis as well as trauma and inadequate immunity are predisposing factors. Surgery remains the treatment of choice, although alternative methods have been used. We report the first known case of a 6cm mycotic splenic artery aneurysm proximal to the splenic hilum, secondary to bacterial endocarditis from Coxiella burnetii. Resection of the aneurysm, splenectomy, and distal pancreatectomy were performed. In all patients with culture-negative endocarditis and mycotic aneurysm, C. burnetii infection should be ruled out.

Ligation-and-Bypass Technique through the Posterior Approach for Bilateral Popliteal Aneurysms

2009-12-25

A 56-year-old man with a painful, progressively enlarging pulsatile mass in the bilateral popliteal fossae was diagnosed with a bilateral popliteal artery aneurysm (PAA) and referred to our hospital to undergo surgical therapy. Computed tomographic scanning demonstrated a large, middle-type PAA with a rich mural thrombus in the bilateral popliteal arteries. Following aneurysm exclusion posteriorly, the patient underwent bypass surgery using a ringed polytetrafluoroethylene graft bilaterally. This procedure was chosen to prevent nerve injury caused by mobilization of the adherent nerves and aneurysmal resection. The patient had a satisfactory postoperative course. This procedure may be recommended for large, middle-type PAAs because (1) the adherent tibial nerve trunk and its branch nerves can be protected by aneurysm exclusion with arterial branch ligation and (2) frequently occurring postexclusion expansion of the aneurysm caused by insufficient branch ligation using the medial approach can be avoided.

Leiomyosarcoma of the Inferior Vena Cava: Case Report and Treatment of Recurrence with Repeat Surgery

2009-12-25

Leiomyosarcoma of the inferior vena cava (IVC) is an extremely rare malignancy with poor prognosis due to late diagnosis. Surgical resection currently remains the best treatment; however, recurrence frequently occurs and the 5-year survival rate is only 31%. The aim of this study is to report a case of IVC leiomyosarcoma and treatment of recurrence with repeat surgery. A 36-year-old woman with a high-grade leiomyosarcoma originating from the infrahepatic IVC underwent an en bloc excision of the tumor. Eleven months after the initial operation, two metastases to the omentum were observed. Since the patient showed no response to adjuvant chemotherapy (i.e., a combination of 5-fluorouracil and gemcitabine), repeat operations were used as the main treatment modality for recurrence. The median time to recurrence was 15 months (range 8–27). The middle and upper IVC segments were involved in the local recurrence, and metastatic lesions occurred in multiple sites including the stomach, omentum, mesentery, left liver, and pelvic cavity. Repeat operations to remove the recurrent and metastatic tumors led to a long–term (at least 7 years) survival, and the patient is still alive. Postoperative recoveries were uneventful. Neither complication related to the venous blood flow in the IVC nor renal impairment was noted. Our results suggest that in the setting of chemotherapy–refractory IVC leiomyosarcoma repeat surgery may be an alternative treatment for recurrence and improve survival time.

Tuberculous Pseudoaneurysm of the Descending Thoracic Aorta

Sun-Cheol Park, In-Sung Moon, Yong-Bok Koh — 2010-01-05

Tuberculous mycotic aortic aneurysm is a rare disease with a high mortality rate. Its prevalent location is the descending thoracic aorta in the patient with disseminated tuberculosis. Most of these aneurysms have been of the pseudoaneurysm type. We report the case of a 37-year-old woman with tuberculous pseudoaneurym of the descending aorta that was initially mistaken for a lung lesion and was successfully repaired surgically.

Internal Iliac Artery Branch Stent Grafting for Aortoiliac Aneurysms Using the Apollo Branched Device

2010-01-05

The association of aortic and common iliac artery aneurysms requires a special strategy to achieve distal seal during the endovascular exclusion of abdominal aortic aneurysms. Coil embolization of the internal iliac artery before the placement of a bifurcated endograft limb into the external iliac artery is a usual option. Such procedures are usually well tolerated but may result in buttock claudication, postprocedural sexual dysfunction, and colonic ischemia. We report on an alternative repair to preserve internal iliac artery patency using the Apollo iliac branched device.

Infection of an Aortic Stent Graft with Suprarenal Fixation

Glenn P. Gardner, Marvin E. Morris, Benjamin Makamson, Rumi M. Faizer — 2009-12-25

We report a case of an elderly man admitted with abdominal pain and fever, 5 months after endovascular aortic aneurysm repair of a suspected inflammatory abdominal aortic aneurysm. He underwent successful explantation of an infected stent graft with suprarenal fixation following extra-anatomic revascularization. After a prolonged hospitalization, he was discharged on antibiotics and at follow-up has returned to baseline activity level. Although explantation of an infected prosthesis following endovascular aortic aneurysm repair has been previously reported, our case prompted a review of the literature to evaluate mode of presentation, putative factors, and management decisions associated with reduced morbidity and mortality.

Congenital External Carotid Artery Aneurysm

2009-12-25

An 8-month-old child presented with a right pulsatile neck mass. The tumor's rapid increase in size and respiratory problems prompted image evaluation. An external carotid artery aneurysm was found, which was compressing other neck structures. The patient underwent aneurysm resection and ligation at its insertion on the common carotid artery. Recovery was uneventful and no further aneurysms on other arteries were found.

Dynamic Human Cadaver Model for Testing the Feasibility of New Endovascular Techniques and Tools

2009-07-21

Endovascular device specifications and technical improvements are strongly required, especially in particular anatomical locations such as the aortic arch and the thoracoabdominal aorta. We present a new technique for total endovascular repair of the aortic arch and an experimental design of a circulation model in the human cadaver in order to evaluate the feasibility of this technique.

Reinfusion of Blood within Aneurysm Sac: A Simple Method of Intraoperative Blood Conservation in Elective Abdominal Aortic Surgery

2009-12-25

Autologous blood conservation reduces postoperative morbidity and mortality. In elective abdominal aortic aneurysm repair, the blood within the aneurysm sac is generally neglected during surgery. We present a simple method of additional blood conservation in elective abdominal aortic surgery, which involves reinfusion of autologous blood within the aneurysm sac in the perioperative period.

Historical Overview of Varicose Vein Surgery

Jephta van den Bremer, Frans L. Moll — 2010-02-08

Varicose veins are as old as Hippocrates. Varicose vein treatments come and go. Surgery for varicose vein disease is one of the commonest elective general surgical procedures. The history of varicose vein surgery has been traced. We note the first descriptions of varicose veins, and we particularly focus on the ligation of the saphenofemoral junction, stripping of the great saphenous veins, phlebectomy, and perforant vein surgery. We end with the rapid rise of minimally invasive procedures, such as foam sclerotherapy, radiofrequency ablation, and endovenous lasertherapy. Within 10 years, the advantages of minimal invasiveness for these procedures, combined with claims of equivalent short-term outcomes and even better long-term results, have already influenced our everyday practice. At present, the gold standard treatment of varicose veins still is surgical ligation and stripping of the insufficient vein. Concomitantly or sequentially with the treatment of truncal insufficiency, residual varicosities can be treated by phlebectomy. New minimally invasive techniques, however, have changed the clinical landscape for varicose vein surgery tremendously. The dramatic changes of the last decade are probably the precursors of the next generation.

2010-04-01

On the Cover

2010-04-01

Annals of Vascular Surgery

Management of Complex Patients with Budd–Chiari Syndrome

Prehospital Treatment of Infrarenal Ruptured Abdominal Aortic Aneurysms: A Multicentric Analysis

A New Preoperative Predictor of Outcome in Ruptured Abdominal Aortic Aneurysms: The Time Before Shock (TBS)

Retroperitoneal Approach to Abdominal Aortic Aneurysm Repair Preserves Splanchnic Perfusion as Measured by Gastric Tonometry

Femoral Artery Complications after Cardiac Catheterization: A Study of Patient Profile

Vertical or Transverse Incisions for Access to the Femoral Artery: A Randomized Control Study

Eligibility for Endovascular Technique and Results of the Surgical Approach to Popliteal Artery Aneurysms at a Single Center

The Impact of Isolated Tibial Disease on Outcomes in the Critical Limb Ischemic Population

Radiofrequency-Powered Segmental Thermal Obliteration Carried out with the ClosureFast Procedure: Results at 1 Year

Intraoperative Adjunctive Stem Cell Treatment in Patients with Critical Limb Ischemia Using a Novel Point-of-Care Device

Combined Distal Venous Arterialization and Free Flap for Patients with Extensive Tissue Loss

Implementation and Efficacy of Selective Sonographic Screening for Carotid Disease before Cardiac Surgery

The Impact of a Systemwide Policy for Emergent Off-Hours Venous Duplex Ultrasound Studies

Bispectral Index Changes in Carotid Surgery

The Effectiveness and Feasibility of Endovascular Coil Embolization for Very Small Cerebral Aneurysms: Mid- and Long-Term Follow-Up

Analysis of Calcifications in Patients with Coral Reef Aorta

Duplication of Superficial Femoral Artery: An Uncommon Variation of the Lower Limb Arterial System

Acute Mesenteric and Aortic Thrombosis Associated With Antithrombin Deficiency: A Rare Occurrence

Congenital Absence of the Left Internal Carotid Artery

Endovenous Therapy for the Treatment of Congenital Venous Malformations

Redo Arch Aneurysm Repair for New-Onset Aortic Arch Dissection Following Ascending Aortic Surgery: Long Elephant Trunk Technique Combined With Trifurcate-Branched Graft

The Use of the Amplatzer Plug to Treat Dysphagia Lusoria Caused by an Aberrant Right Subclavian Artery

Endovascular Treatment of Massive Thoracic Aortic Thrombus and Associated Ruptured Atheroma

Mycotic Splenic Artery Aneurysm Secondary to Coxiella burnetii Endocarditis

Ligation-and-Bypass Technique through the Posterior Approach for Bilateral Popliteal Aneurysms

Leiomyosarcoma of the Inferior Vena Cava: Case Report and Treatment of Recurrence with Repeat Surgery

Tuberculous Pseudoaneurysm of the Descending Thoracic Aorta

Internal Iliac Artery Branch Stent Grafting for Aortoiliac Aneurysms Using the Apollo Branched Device

Infection of an Aortic Stent Graft with Suprarenal Fixation

Congenital External Carotid Artery Aneurysm

Dynamic Human Cadaver Model for Testing the Feasibility of New Endovascular Techniques and Tools

Reinfusion of Blood within Aneurysm Sac: A Simple Method of Intraoperative Blood Conservation in Elective Abdominal Aortic Surgery

Historical Overview of Varicose Vein Surgery

Table of Contents

On the Cover