Annals of Vascular Surgery - Articles in Press

Endovenous Laser Ablation: A Review of Mechanisms of Action - Corrected Proof

Marc E. Vuylsteke, Serge R. Mordon — 2012-02-03

Background: The aim of this article is to summarize and review the proposed theories on the laser action during endovenous ablation.Methods: Laser mechanics and laser–tissue interaction are summarized from articles found in literature. Several theories, like the “steam bubble theory,” the “direct contact theory,” the “heat pipe,” and “direct light energy absorption” are discussed.Results: The laser light emitted intraluminally can be absorbed, scattered, or reflected. Reflection is negligible in the near-infrared spectrum. By combining absorption and scattering, the optical extinction of different wavelengths related to different biological tissues can be determined. The direct contact of the fiber tip and the vein wall may be a way of destroying the vein wall, but results in ulcerations and perforations of the vein wall. Avoiding this contact, and allowing direct light absorption into the vein wall, results in a more homogenous vein wall destruction. If the energy is mainly absorbed by the intraluminal blood, the laser fiber will act as a heat pipe. Histological studies show that a more circumferential vein wall destruction can be obtained when the vein is emptied of its intraluminal blood. The use of tumescent liquid reinforces spasm of the vein and protects the perivenous tissue.Conclusion: Several factors play an important role in the mechanism of endovenous laser ablation. Direct energy absorption by the vein wall is the most efficient mechanism. It is important to empty the vein of its intraluminal blood and to inject tumescent liquid around the vein.

Randomized Trials in Angioplasty and Stenting of the Renal Artery: Tabular Review of the Literature and Critical Analysis of Their Results - Corrected Proof

Guillermo A. Escobar, Danielle N. Campbell — 2012-02-03

As the incidence of hypertension (HTN) continues to rise, finding the optimal treatment of this multifactorial disease is critical. Renal artery stenosis (RAS) is a known etiology for HTN and is associated with declining renal function. Other than medications, the original gold standard for treatment of HTN from RAS was with an open surgical revascularization or nephrectomy. Since then, endovascular interventions for RAS have been reported to be technically possible, but their efficacy over medications or surgery has yielded conflicting results in case series and randomized trials. This tabular review summarizes the results of randomized trials that compared the outcomes of endovascular renal artery interventions with nonendovascular techniques (including medical and surgical treatments) for the treatment of HTN and renal dysfunction. Based on these data, the strengths and weaknesses of individual trials are critically analyzed to better define the methods to identify and treat patients with RAS.

Surgically Relevant Aortic Arch Mapping Using Computed Tomography - Corrected Proof

Adrienne Finlay, Marjorie Johnson, Thomas L. Forbes — 2012-02-03

Background: Recent advances in surgical repair of aortic arch pathologies have increasingly used endovascular stent-graft technology. The purpose of this study was to map the aortic arch diameters, branch orientations, and center line distances using a commercially available three-dimensional computed tomography-based software package and to propose a prototype design.Methods: TeraRecon 3D imaging software was used for morphological assessment of computed tomography scans from 45 patients (mean age: 68 years; 26 males, 19 females). In each patient, 13 measurements were made in relation to the center line, including diameters at several preset points, distances, and branch vessel orientations.Results: The mode of the proximal diameters (2 cm and 4 cm distal to coronary artery) was 32 mm and 34 mm. The mode of the distance between the innominate and left common carotid arteries was 5 mm and 6 mm, and the mode of the distance between the left common carotid artery and left subclavian artery was 8 mm. Most commonly, the left common carotid artery was anterior to the other arch branches by 3 to 5 mm.Conclusions: These anatomic measurements provide useful information for the advancement of minimally invasive and safer surgical repair of the aortic arch. Based on the most commonly observed measurements, a standardized off-the-shelf stent-graft is proposed that would be appropriate for the majority of patients.

Dialysis Access - Corrected Proof

Patrick A. Stone, Albeir Y. Mousa, John E. Campbell, Ali F. AbuRahma — 2012-02-01

Although hemodialysis access procedures are considered the most common vascular procedures performed by either general or vascular surgeons, there is a paucity of level-one evidence in the literature. Randomized controlled trials are limited, and most of these studies have small sample sizes compared with other areas of vascular surgery, that is, carotid or aneurysm studies. We summarize the results of the world's literature for arteriovenous access in table format as a tool for those specialists managing patients with arteriovenous access procedures.

Outcome of Infrainguinal Single-Segment Great Saphenous Vein Bypass for Critical Limb Ischemia is Superior to Alternative Autologous Vein Bypass, Especially in Patients With High Operative Risk - Corrected Proof

Eva Arvela, Maarit Venermo, Maria Söderström, Anders Albäck, Mauri Lepäntalo — 2012-01-30

Background: Single-segment great saphenous vein (ssGSV) is the conduit of choice in infrainguinal bypass for critical limb ischemia (CLI). The aim of this study was to assess results of other autologous vein grafts and risk factors for graft stenosis development and graft failure. The purpose was also to evaluate outcome of patients with high operative risk undergoing infrainguinal alternative autologous vein bypass for CLI.Methods: We retrospectively reviewed 1,109 consecutive infrainguinal bypasses performed between 2000 and 2007 for CLI. Rate and type of operations needed to maintain graft patency were evaluated. Outcome of different types of vein grafts in terms of primary patency, assisted primary patency, secondary patency, and limb salvage was assessed using Kaplan–Meier method. Predictors of poor outcome as well as patient- and graft-related risk factors for graft revision and graft failure were analyzed using multivariate analysis.Results: Median follow-up period was 37 (0–121) months. Primary patency, assisted primary patency, secondary patency, and limb salvage at 1 and 3 years were significantly better in ssGSV graft group than in alternative autologous vein graft (AAVG) group—74.4% and 67.1% versus 53.7% and 42.0% (P < 0.0001), 82.8% and 78.2% versus 67.2% and 57.8% (P < 0.0001), 84.8% and 80.8% versus 69.9% and 61.4% (P < 0.0001), and 88.9% and 86.9% versus 83.0% and 77.2% (P < 0.0001), respectively. In multivariate analysis, non-ssGSV graft was the only independent risk factor for the graft stenosis development (relative risk [RR]: 2.62, 95% confidence interval [CI]: 1.56–4.38, P < 0.0001), for graft occlusion (RR: 2.27, 95% CI: 1.52–3.40, P < 0.0001), and for graft failure (stenosis or occlusion) (RR: 2.00, 95% CI: 1.39–2.88, P < 0.0001). Revision rate of non-ssGSV conduits was higher than that of ssGSV grafts (18% vs. 12%, P = 0.007) High-risk patients (age of >80 years, coronary artery disease, estimated glomerular filtration rate of <30 mL/min/1.73 m2) who underwent bypass with arm vein or spliced vein had extremely poor outcome (1-year leg salvage rate and survival rate of 71.4% and 28.6%, respectively).Conclusion: The ssGSV graft is superior to any other autologous vein graft in terms of midterm patency and leg salvage. It also needs less maintenance procedures than AAVGs. Non-ssGSV graft is independent predictor of both graft stenosis development and graft failure. Acceptable patency and leg salvage rates can also be achieved with AAVGs. However, patients with high operative risk and non-ssGSV graft bypass have poor outcome.

Endovascular Stent-Graft Placement or Open Surgery for the Treatment of Acute Type B Aortic Dissection: A Meta-Analysis - Corrected Proof

Zhang Hao, Wang Zhi-Wei, Zhou Zhen, Hu Xiao-Ping, Wu Hong-Bing, Guo Yi — 2012-01-30

Background: Acute type B aortic dissection (ATBAD) is a life-threatening condition. Open chest surgical repair using a prosthetic graft has been a conventional treatment for ATBAD. During the past decade, thoracic endovascular aortic repair (TEVAR), which is considered as a less invasive and potentially safer technique, has been increasingly used to treat this condition. Evidence is needed to support the use of TEVAR for these patients. The aim of this review was to assess the efficacy of TEVAR versus conventional open surgery in patients with ATBAD.Methods: For this review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched: 2010, issue 4), MEDLINE, EMBASE, CINAHL, Web of Science, and the Chinese Biomedicine Database for clinical trials until January 18, 2011. Controlled trials in which patients with ATBAD were assigned to TEVAR or open surgical repair were included. For each outcome, we evaluated the quality of the evidence with reference to the Grading of Recommendations Assessments, Development, and Evaluation criteria. At the end, we used RevMan 5.0 software to analyze the datum.Results: Five trials (318 participants) are included in this review. As determined by the Grading of Recommendations Assessments, Development, and Evaluation approach, the result quality was low for 30-day mortality and very low for other variables. TEVAR can significantly reduce the short-term mortality for ATBAD (Mantel–Haenszel fixed odds ratio [95% confidence interval]: 0.19 [0.09–0.39], P < 0.001). TEVAR cannot significantly improve postoperative complications or long-term mortality.Conclusions: TEVAR can be weakly recommended as an alternative for the selective treatment of ATBAD but cannot always be used in case of surgery.

Buerger’s Disease - Corrected Proof

Phong T. Dargon, Gregory J. Landry — 2012-01-27

Buerger’s disease (thromboangiitis obliterans) is a nonatherosclerotic segmental inflammatory disease of small- and medium-sized arteries of the distal extremities of predominantly young male tobacco users. Early symptoms may include episodic pain and coldness in fingers, and late findings may present as intermittent claudication, skin ulcers, or gangrene requiring eventual amputation. Tobacco cessation is the cornerstone of treatment. Other modalities of reducing pain or avoiding amputation have not been as successful. This review summarizes in tabular form the types of treatment that have been used, including therapeutic angiogenesis.

Short-term Outcomes for Open Revascularization of Chronic Mesenteric Ischemia - Corrected Proof

Daniel L. Davenport, Armin Shivazad, Eric D. Endean — 2012-01-27

Background: Surgical bypass as treatment for chronic mesenteric ischemia (CMI) is performed to alleviate symptoms of weight loss and postprandial pain and to prevent catastrophic intestinal necrosis. Among the studies that report outcomes for mesenteric bypass, few focus on the type of conduit. The purpose of this study was to evaluate contemporary short-term outcomes of patients who underwent aortomesenteric bypass for CMI, with specific attention given to the conduit used—prosthetic versus vein.Methods: Data from the American College of Surgeons National Surgical Quality Improvement Program Participant Use File were analyzed for demographic and clinical risk variables, mortality, and 22 defined complications (morbidity) between 2005 and 2009 from more than 200 participating hospitals. The database was queried for patients undergoing aortomesenteric bypass with vein (Current Procedural Terminology [CPT] 35531) or nonvein (CPT 35631) whose preoperative diagnosis was CMI (International Classification of Diseases, 9th Revision code 557.1). Outcomes and risk variables were compared using univariate analysis and independent sample t tests for continuous variables.Results: One hundred fifty-six patients underwent mesenteric revascularization—119 (76%) women and 37 (24%) men with an average age of 65 ± 13 years. The conduit used was vein in 44 (28%) and prosthetic graft in 112 (72%). There were no statistically significant differences between the two groups in mean age, smoking history, recent weight loss, obesity (body mass index: >25) rates, length of operation, reoperation frequency, and early graft failure. More patients undergoing bypass with vein had an associated bowel resection and preoperative sepsis or systemic inflammatory response syndrome. Additionally, patients with a vein graft had a higher percentage of a contaminated surgical site (30% vs. 7%, P = 0.001) and underwent emergent surgery more frequently (16% vs. 4%, P = 0.012). Mortality was higher in patients in whom a vein graft was used (16% vs. 5%, P = 0.039). There were no differences noted between the two groups in length of stay or postoperative complications, including infectious complications, renal insufficiency, myocardial infarction, and stroke.Conclusions: Thirty-day mortality was higher in patients who underwent mesenteric bypass with vein. However, this group also had a higher incidence of emergent surgery, bowel resection, and contaminated operative field. This suggests that vein grafts were preferentially used when bowel infarction was suspected. The higher mortality is likely due to patient factors, such as the extent of bowel ischemia at the time of operation, rather than the type of conduit used. If expeditious revascularization is done before development of bowel infarction, vein or prosthetic conduit would be expected to function equally well.

Experience and Outcomes After a Decade of Endovascular Abdominal Aortic Aneurysm Repair: A Retrospective Study From a Community-Based Single Center - Corrected Proof

2012-01-27

Background: The purpose of this study is to report the results of endovascular abdominal aortic aneurysm treatment based on the Zenith stent–graft from a community-based single center over a period of 9 years.Methods: We retrospectively analyzed immediate technical and clinical results as well as long-term outcomes in patients treated with endovascular aneurysm repair between 2001 and 2010. The study was performed in accordance with the recommendations of the ad hoc committee for standardized reporting practice in vascular surgery.Results: A total of 106 patients were treated in a period of 9 years. A Zenith stent–graft was used in 95% of cases. No deaths occurred during the first 30 days postsurgery. The complication rate was 4.7% (n = 5). The overall clinical and technical success rate at 30 days was 93.4%. After a mean follow-up period of 52 months (range, 13–112 months), the overall mortality rate was 25.4%. Aneurysm-related mortality was 2.1%. Rupture of the aneurysm occurred in four cases (4.3%). The final clinical failure rate was 13.8%. During the follow-up period, the mean diameter of the aneurysm decreased from 58.0 to 52.3 mm. However, expansion of the aneurysm was registered in 10 cases. Eleven patients had a primary endoleak, and another 11 secondary endoleaks occurred during the follow-up. The reintervention rate was 16.3%. The main reasons for repeat interventions were iliac limb occlusion (n = 5) and type 3 endoleak/limb disconnection (n = 4). Graft migration occurred in 3% of cases. A negative impact on sexual function after endovascular repair was reported by 20% of patients.Conclusion: Endovascular repair is the treatment of choice for high-risk patients. A small but significant number of clinical failures were observed during the long-term follow-up.

Hybrid Repair of Aortic Arch Aneurysm - Corrected Proof

2012-01-27

Hybrid repair of thoracic aortic aneurysm has been used with increasing frequency over the past decade, as indications for endovascular therapy have continued to expand. Hybrid techniques may avoid and limit the morbidity and mortality associated with sternotomy or thoracotomy, mechanical circulatory support, and hypothermic arrest. We present the case of a patient with extensive aortic aneurysmal disease initially needing open ascending aortic and subsequent thoracoabdominal repair. However, owing to continued enlargement of the aortic arch, hybrid extrathoracic, extra-anatomic complete aortic arch debranching and transcatheter endografting was ultimately pursued with favorable midterm results.

Massive Pulmonary Embolism Caused by Internal Iliac Vein Thrombosis With Free-Floating Thrombus Formation in the Inferior Vena Cava - Corrected Proof

2012-01-27

Nowadays, compression ultrasonography (CUS) is the gold standard for the routine diagnosis of deep venous thrombosis (DVT). The drawback of CUS is the low sensitivity concerning the diagnosis of isolated pelvic vein thrombosis, especially referring to isolated internal iliac vein and ovarian vein thromboses. Therefore, magnetic resonance (MR) venography has become a valuable alternative. We present the case of a 45-year-old female patient with a massive pulmonary embolism with the indication for thrombolytic therapy due to severe right ventricular overload. We were not able to detect a DVT in the lower limbs of this patient with CUS. However, further DVT workup by MR venography showed a free-floating thrombus formation originating from the right internal iliac veins into the inferior vena cava. Owing to the fact that this thrombus was free floating, surgical removal of the thrombus was scheduled and performed successfully. In some patients it might be important to look for so-called rare causes of pulmonary embolism, even when CUS of the lower limbs does not reveal any DVTs. The diagnostic procedure of choice for these patients seems to be MR phlebography, as iliac and pelvic veins can be evaluated without radiation exposure with this procedure.

Pull-Through Technique With Pincer Tactics for Stent Placement in Severe Superior Vena Cava Syndrome - Corrected Proof

2012-01-27

The pull-through technique is an interventional radiological procedure used when an occluded lesion cannot be traversed from one direction. To pass the lesion, a long guidewire is traversed from the opposite side and pulled through the ipsilateral sheath using a snare wire. The present report describes a case of severe superior vena cava syndrome treated by stent placement using a pull-through technique with pincer tactics. We successfully placed a stent in the occluded right internal jugular vein to the superior vena cava using a bilateral approach by snaring a guidewire in the right subclavian vein.

Retrograde Approach for Endovascular Salvage of an Infrapopliteal Vein Bypass - Corrected Proof

2012-01-27

Endovascular treatment through femoropopliteal and infragenicular percutaneous transluminal angioplasty, both in native vessels and in bypass salvage, has been an emerging technique in recent years. However, in some cases, a difficult anterograde access in distal occlusions has limited the technical success of this procedure. Combined subintimal arterial flossing with antegrade–retrograde intervention is used as a resource technique to obtain precise recanalization in these cases. Here, we present the case of a retromalleolar access of the posterior tibial artery, based on subintimal arterial flossing with antegrade–retrograde intervention technique, to achieve femoral–posterior tibial bypass salvage.

Management of Traumatic Aortic Isthmus Rupture in Case of Aberrant Right Subclavian Artery (Arteria Lusoria) - Corrected Proof

2012-01-27

Background: To present an unusual case of blunt aortic injury in a 30-year-old male patient with an aberrant right subclavian artery.Methods and Results: Driven by the complicated and challenging nature of the case, we decided to treat the patient by a combined approach—right subclavian artery transposition and endograft implantation at the isthmus level. During the 24-month follow-up (clinical examination, angiogram, computed tomographic scan), we registered no complaints; normal perfusion of the right arm; and adequate sealing of the aortic tear.Conclusions: We believe that the hybrid management of such trauma is a feasible, effective, and less-invasive option.

Surgical Removal of a Knotted and Entrapped Subclavian Hemodialysis Catheter Guidewire - Corrected Proof

2012-01-27

Many mechanical complications associated with insertion, maintenance, and removal of the hemodialysis catheters have been reported in the literature. A 47-year-old man was consulted to our hospital because of an entrapped hemodialysis catheter guidewire. Computed tomographic scan revealed that the right subclavian vein was perforated by the guidewire and the wire was knotted over itself, one loop inside the vein and two loops in the extravascular site. Guidewire is pulled out from a 3-cm incision over the wire loops lateral to the right sternocleidomastoid muscle. He was discharged home on postoperative day 2 without any complication. Our suggestion is that any abnormal resistance should be immediately evaluated for the presence of any potential knots using the most appropriate imaging technique.

Spontaneous Resolution of Cystic Adventitial Disease: A Word of Caution - Corrected Proof

Li Zhang, Randy Guzman, Iain Kirkpatrick, Julianne Klein — 2012-01-27

Spontaneous resolution of cystic adventitial disease has been occasionally reported in the literature. It is unclear, however, whether this resolution is permanent. In this case report, we describe recurrence of a popliteal artery cystic adventitial disease after spontaneous resolution, which was successfully treated with surgery. The underlying mechanism is proposed. Without definitive treatment, the patients with spontaneous resolution of cystic adventitial disease may need long-term follow-up, given the risk of recurrence.

Nonanastomotic Pseudoaneurysm With Complete Disruption of an Expanded Polytetrafluoroethylene Axillofemoral Bypass Graft - Corrected Proof

Shintaro Shibutani, Hideaki Obara, Toshihiro Kakefuda, Yuko Kitagawa — 2012-01-27

Rupture of an expanded polytetrafluoroethylene (ePTFE) vascular graft is rare. We report a nonanastomotic pseudoaneurysm associated with complete disruption of an ePTFE graft that occurred 6 years after an axillofemoral bypass. The 81-year-old patient had undergone neither trauma nor infection. The aneurysmal segment was resected, and a new ePTFE graft was interposed. The patient recovered uneventfully and was well 4 years later. Histologic analysis revealed a torn graft edge, consistent with a rupture due to excessive force, but scanning electron microscopy showed that the internal structure of the prosthesis was intact. The cause of the midgraft rupture remains unknown.

Combined Revascularization and Free-Tissue Transfer for Limb Salvage in a Buerger Disease Patient - Corrected Proof

2012-01-27

Buerger disease is a limb-threatening condition occurring in young smokers, and its treatment has been a challenging problem, although a large number of medical and surgical options have been suggested. Combined surgery for revascularization and free-tissue transfer for Buerger disease is an aggressive and attractive option. This complex surgery enables successful treatment of tissue loss caused by ischemia. We performed revascularization and free-tissue transfer to the critically ischemic limb in a patient with Buerger disease. In this case, the procedure is attempted to salvage a limb from amputation.

Aortoenteric Fistula Treated With Endovascular Aortic Stent-Graft and Bilateral Chimney Stent-Grafts to Renal Arteries - Corrected Proof

2012-01-27

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.

How to Avoid a Difficult Groin in Redo Arterial Surgery: Eversion Endarterectomy of the Proximal Superficial Femoral Artery Versus Profunda Femoris Artery as Inflow for Distal Bypass - Corrected Proof

Antonio Cavallaro, Antonio V. Sterpetti, Paolo Sapienza, Luca Dimarzo — 2012-01-27

Background: The aim of the study was to describe and analyze the results of a technique in which the inflow for distal bypasses is provided by the proximal superficial femoral artery, reopened through an eversion endarterectomy, to avoid a “difficult groin.”Material and Methods: Twenty-one patients who underwent distal bypass for severe lower-limb ischemia and in whom the proximal superficial femoral artery was reopened with an eversion endarterectomy to provide inflow for the bypass itself were included in the study. As a comparison group, 20 patients in whom the inflow for a distal bypass was obtained by the distal deep femoral artery were randomly selected. In all 41 patients, the groin was considered “difficult” because of multiple previous operations.Results: Five-year cumulative patency rates were 53% for femoropopliteal bypasses and 40% for femorotibial bypasses. Similar patency rates were obtained when the distal deep femoral artery was used as inflow.Conclusions: Eversion endarterectomy of the proximal superficial femoral artery provides a valid source of inflow for distal bypasses, and it should be kept in the armamentarium of the vascular surgeon, to be used in selected cases.

Patients Characteristics and Outcome of 518 Arteriovenous Fistulas for Hemodialysis in a sub-Saharan African Setting - Corrected Proof

2012-01-27

Background: To present the particular aspects of arteriovenous fistula (AVF) for hemodialysis in sub-Saharan Africa in terms of patients’ characteristics, patency and complication rates, as well as factors influencing them.Methods: From November 2002 to November 2009, 518 fistulas were constructed on adults. Demographic data, patency, and complications were analyzed. The association between age, sex, and comorbidities (HIV, hypertension, diabetes) on one hand and complications as well as AVF patency on the other was sought.Results: Males represented 73.7% of the patient population, and the mean age of the population was 45.3 years. As far as etiologies of end-stage renal disease (ESRD) and comorbidities are concerned, chronic glomerulonephritis was the leading cause of ESRD (134; 25.9%), followed by hypertension (22.3%), although prevalent in 83.2% of patients, and diabetes (20.1%), although prevalent in 22.2%. No cause for the ESRD could be identified in 89 patients (17.2%). Only 20.64% had AVF as the initial vascular access. The main types of AVF constructed were radiocephalic (68%) and brachiocephalic (24.9%). The median follow-up period was 275 days. The cumulative patency rate at 1 year and 2 years was 76% and 51%, respectively. Altogether, 188 complications occurred in 16% of the AVFs. Aneurysms, failure to mature, and thrombosis were the most frequent complications occurring in 27.65%, 14.89%, and 10.63% of cases, respectively. The management options for the complications included the creation of a new access for 63 complications (33.51%) and nonoperative management in 44.14% of the cases. We found no adverse effect of comorbid factors like diabetes mellitus (χ2 = 3.58, P > 0.05) and HIV-positive status (χ2 = 0.64, P > 0.05) on the complications rate.Conclusion: According to our patients’ characteristics, there is a possibility of constructing AVF on nearly every hemodialysis patient with a good outcome.

Increased Pulse Wave Velocity and Arterial Hypertension in Young Patients With Thoracic Aortic Endografts - Corrected Proof

2012-01-27

Background: Hypertension after thoracic endovascular aortic repair (TEVAR) is a medical complication not widely investigated. The aim of the study was to test the hypothesis that TEVAR in young patients suffering from thoracic aortic transection alters pulse wave velocity (PWV) and reflected wave velocity and induces arterial hypertension.Methods: The data concerning 11 young patients (all men with a mean age of 26.9 years [range: 18–33]) treated with TEVAR for thoracic aortic transection were retrospectively collected and analyzed. PWV, systolic blood pressure (SBP), and pulse pressure (PP) were evaluated and compared with those recorded in 11 healthy young individuals matched for age and gender.Results: Nine patients had postoperative arterial hypertension after TEVAR, and four had durable hypertension during the follow-up period (13–66 months after TEVAR). The SBP, the PP, and the PWV of the patients were greater compared with those of the control group (SBP: 134.1 ± 13.7 vs. 121.36 ± 7.1 mm Hg, P = 0.016; PP: 60.45 ± 19.42 vs. 44.1 ± 4.37, P = 0.020; and PWV: 10.41 ± 2.85 vs. 7.45 ± 0.66 m/sec, P = 0.006).Conclusions: Aortic endografts could produce a discontinuation of the pulsatile waves with a subsequent increase of aortic PWV. Increased PWV is an important risk factor for future cardiovascular events and should be evaluated in all patients after TEVAR.

Clinical Outcome After Extended Endovascular Recanalization in Buerger’s Disease in 20 Consecutive Cases - Corrected Proof

2012-01-27

Background: To present our experience of extended endovascular management for thromboangiitis obliterans (Buerger’s disease) patients with critical limb ischemia (CLI).Methods: Between January 2005 and July 2010, a consecutive series of 17 Buerger’s disease patients with CLI in 20 limbs were admitted and the diagnosis confirmed. The mean age of the patients was 41.5 years (standard error: ±1.7). All patients presented with history of smoking, one patient presented with hypertension, and eight patients presented with dyslipidemia. According to Rutherford classification, all patients were found to be between grades 3 and 5. Ultrasonography first, and angiography examination later, confirmed a severe arterial disease involving almost exclusively below-the-knee and foot arteries in all cases. A new approach for revascularization, defined as extended angioplasty of each tibial and foot artery obstruction, was performed to achieve direct perfusion of at least one foot artery.Results: An extensive endovascular treatment was intended in all patients with success in 19 of 20 limbs, achieving a technical success in 95%. No mortality or complication related to the procedure was observed. During a mean follow-up of 23 months (standard error: ±4.05), amputation-free survival with no need of major amputation in any case and sustained clinical improvement was achieved in 16 of the 19 limbs (84.2%) successfully treated, resulting in a 100% limb salvage rate (19/19).Conclusion: In this first experience, in patients with thromboangiitis obliterans, extended endovascular intervention was a feasible and effective revascularization procedure in case of CLI. High technical success, amputation-free survival, and sustained clinical improvement rates were achieved at midterm follow-up was achieved.

Temporal Artery Biopsy is not Required in all Cases of Suspected Giant Cell Arteritis - Corrected Proof

2012-01-27

Background: Temporal artery biopsy (TAB) is performed during the diagnostic workup for giant cell arteritis (GCA), a vasculitis with the potential to cause irreversible blindness or stroke. However, treatment is often started on clinical grounds, and TAB result frequently does not influence patient management. The aim of this study was to assess the need for TAB in cases of suspected GCA.Methods: We performed a retrospective review of 185 TABs performed in our institution from 1990 to 2010. Patients were identified through the Hospital In-Patient Enquiry database and theater records. Clinical findings, erythrocyte sedimentation rate, steroid treatment preoperatively, American College of Rheumatology (ACR) criteria for GCA score, biopsy result, and follow-up were recorded.Results: Fifty-eight (31.4%) biopsies were positive for GCA. Presence of jaw claudication (P = 0.001), abnormal fundoscopy (P = 0.001), and raised erythrocyte sedimentation rate (P = 0.001) were significantly associated with GCA. The strongest association with positive biopsy was seen with the prebiopsy ACR score (P < 0.001). Twenty-four (13.7%) patients had undergone biopsy, despite no potential for meeting ACR criteria preoperatively. None of these were positive. Overall, 29 (16.4%) patients had management altered by TAB result.Conclusions: Our results confirm that TAB does not affect management in the majority of patients with suspected GCA. We conclude that TAB has benefit only for patients who score 2 or 3 on the ACR criteria for GCA without biopsy.

Role of Statin Therapy and Angiotensin Blockade in Patients With Asymptomatic Moderate Carotid Artery Stenosis - Corrected Proof

2012-01-27

Background: The purpose of this study was to evaluate the 10-year outcome of patients presenting with asymptomatic moderate carotid artery stenosis, and to determine which factors correlate with progression of disease to stroke or revascularization.Methods: A retrospective review of all new patients presenting with asymptomatic moderate carotid artery stenosis from July 1998 to December 2001 was undertaken. Patients were consecutively identified and included by using duplex ultrasonography to identify moderate carotid disease. Variables were recorded for all patient encounters through June 2010. The primary end point was occurrence of ipsilateral cerebrovascular stroke or revascularization event (SORE). Statin therapy and angiotensin blockade (STAB) were categorized as follows: STAB0—medical treatment with neither statin therapy nor angiotensin blockade, STAB1—treatment with only one of the two, STAB2—treatment with both. An amortized cost model analyzed the cost of SORE-free survival.Results: Over a 42-month period, 468 carotids in 366 patients with an average age of 69.0 ± 8.7 years were evaluated. Over a mean follow-up of 6.6 ± 2.7 years, SORE occurred in 150 (32.1%) carotid arteries. Hyperlipidemia was predictive of SORE (hazard ratio [HR]: 1.543, 95% confidence interval [CI]: 1.053–2.262, P = 0.03). Medical therapies protective against SORE were beta-blockade (HR: 0.612, 95% CI: 0.435–0.861, P < 0.05), STAB1 (HR: 0.487, 95% CI: 0.336–0.706, P < 0.01), and STAB2 (HR: 0.149, 95% CI: 0.089–0.248, P < 0.01). At 10 years, SORE-free survival in STAB2 was 82.7% ± 4.6%, STAB1 was 56.3% ± 5.0%, and STAB0 was 29.3% ± 5.4% (P < 0.01). The cost per SORE-free year in STAB2 was $1,695.40 ± $275.60, STAB1 was $3,916.80 ± $605.44, and STAB0 was $4,126.40 ± $427.23 (P < 0.01).Conclusion: These data demonstrate the clinical and financial advantage of using both statin therapy and angiotensin pathway blockage in patients with asymptomatic moderate carotid artery stenosis.

Reliability and Repeatability of Toe Pressures Measured With Laser Doppler and Portable and Stationary Photoplethysmography Devices - Corrected Proof

Lukas W. Widmer, Pirkka Vikatmaa, Pekka Aho, Mauri Lepäntalo, Maarit Venermo — 2012-01-27

Background: There are two principally different methods for measuring toe pressures (TP)—photoplethysmography (PPG) and laser Doppler (LD). PPG is based on detecting changes in the blood filling of the digital arteries and arterioles, and the LD perfusion signal is derived from the Doppler shift undergone by the emitted infrared laser light after reflection from moving particles (red blood cells). The aim of the study was to compare two PPG devices and one LD device in TP measurement. The PPG devices used were the Nicolet VasoGuard (Nicolet Vascular Inc, Madison, WI; PPG1) and Systoe (Atys Medical, France; PPG2), and the LD device was the Perimed system 5000 (Perimed, Stockholm, Sweden).Materials and Methods: TPs were measured from 54 nonselected consecutive patients who visited the vascular surgical outpatient clinic or underwent an endovascular procedure owing to chronic lower limb ischemia. A total of 107 toes were measured. The symptoms were claudication in 51.4% (n = 55), rest pain in 4.7% (n = 5), and ulcer or gangrene in 14.0% (n = 15) of the legs. Of the measured legs, 29.9% (n = 32) were asymptomatic. Forty patients had undergone endovascular revascularization immediately before the TP measurement. The limits of agreement show the estimated range within which the differences between measurements by the two devices would fall in approximately 95% of the measurements. The approximate 95% limits of agreement were calculated as the mean difference ± 2 standard deviation and presented in the Bland–Altman scatter plots.Results: For PPG1 versus LD, the mean difference between two measurements was 14 mm Hg and the limits of agreement were 38 mm Hg. In 47% of the toes, the difference was ≥10 mm Hg, and in 37% of the toes, it was ≥15 mm Hg. For PPG2 versus LD, the mean difference between the TPs was 12 mm Hg and the limits of agreement were 24 mm Hg. In 44% of the cases, the difference was ≥10 mm Hg, and in 30%, it was ≥15 mm Hg. For PPG1 versus PPG2, the mean difference between two measurements was 14 mm Hg and the limits of agreement were 24 mm Hg. In 50% of the cases, the difference between the two machines was ≥10 mm Hg, and in 33%, it was ≥15 mm Hg. Repeatability measured with LD, PPG1, and PPG2 showed that the difference between the first and second measurement was <10 mm Hg in 93%, 86%, and 78% of the cases, respectively, and <15 mm Hg in 98%, 94%, and 88% of the cases, respectively.Conclusions: TP values vary greatly depending on the device used. However, the repeatability seemed to be acceptable with LD and PPG1. We recommend using same device when circulation is repeatedly assessed in the same patient. Also, we emphasize the importance of clinical examination and low threshold for angiography and revascularization especially in diabetics with wound healing problems.

Accuracy of Digital Subtraction Angiography, Computed Tomography Angiography, and Magnetic Resonance Angiography in Grading of Carotid Artery Stenosis in Comparison With Actual Measurement in an In Vitro Model - Corrected Proof

2012-01-27

Background: The aim of this study was to investigate the accuracy of digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) in grading of carotid stenosis compared with actual measurement in an in vitro model.Methods: Various grades of stenosis were created by adhering different amounts of silicone rubber sealant onto the inner wall of clear, radiolucent tubes. After DSA, CTA, and MRA, the tubes were transected with 1-mm interval through the plaques. The cross-sectional areas were digitally photographed, and the percentage of area reduction of every single slide was measured with ImageJ planimetric software. The maximum actual area reduction (AAR) stenosis of each tube was recorded. The differences among DSA, CTA, MRA, and AAR were compared statistically using paired Student t test.Results: Overall, CTA and MRA significantly underestimated the degrees of stenosis compared with AAR (P = 0.001 and P = 0.0009, respectively), and no significant difference was found between DSA and AAR (P = 0.40). In the subgroup with stenosis of <70%, there was no significant difference between DSA, CTA, and MRA versus AAR (P = 0.18, P = 0.16, and P = 0.08, respectively). In the subgroup with severe stenosis of >70%, CTA and MRA significantly underestimated the stenosis versus AAR (P = 0.004, and P = 0.007 respectively), and DSA significantly overestimated the stenosis (P = 0.0007).Conclusions: This in vitro model study demonstrated that CTA and MRA underestimate the lesions in severe stenosis of >70%. DSA tends to overestimate the disease. The accuracy of DSA is affected by plaque morphology, such as mountain-shaped lesions.

Hormone Replacement Therapy is Associated With a Decreased Prevalence of Peripheral Arterial Disease in Postmenopausal Women - Corrected Proof

2012-01-27

Background: The effect of hormone replacement therapy (HRT) in postmenopausal women on the development of peripheral atherosclerosis remains in question. The goal of this study was to analyze the use of HRT in a large population of postmenopausal women and to determine its association with the prevalence of peripheral arterial disease (PAD).Methods: A prospective database of patients who underwent voluntary vascular screening was used. Identification of patients as postmenopausal, and their use of HRT, was based on patient questionnaires. PAD was defined to be present if either lower extremity ankle–brachial index was ≤0.9.Results: Analysis was performed on data from 847,982 postmenopausal women; 433,178 (51.1%) reported having used HRT. HRT subjects were slightly older than patients who had not used HRT (64.5 years vs. 63.6 years). Caucasian women were significantly more likely to have used HRT than non-Caucasian women (52.4% vs. 47.6%). HRT subjects were significantly more likely to have smoked cigarettes (42.8% vs. 40.6%), to have hypertension (47.9% vs. 45.1%), and to have hypercholesterolemia (55% vs. 51.5%) than women who had not used HRT (all P < 0.001). However, HRT subjects were significantly less likely to have diabetes mellitus (8.6% vs. 10.2%, P < 0.001). Despite the increased prevalence of several atherosclerotic risk factors among women who used HRT, they were significantly less likely to have PAD (3.3% vs. 4.1%, P < 0.001). Multivariate analysis adjusting for age, race, and medical comorbidities that predispose toward the development of atherosclerosis confirmed that HRT was independently associated with a decreased risk of PAD (odds ratio: 0.8, 95% confidence interval: 0.78–0.82). In subsets of postmenopausal women with known atherosclerotic risk factors, the significant effect of HRT on the prevalence of PAD was maintained; in women with either a smoking history, hypertension, hypercholesterolemia, diabetes, or age of ≥70 years, the odds ratio of HRT use with regard to PAD remained approximately 0.8.Conclusions: The use of HRT in postmenopausal women appears to be associated with a significant reduction in the prevalence of PAD in this population-based study. This association appeared to be significant even in postmenopausal women with known atherosclerotic risk factors. These observational data may suggest a relationship between HRT and the prevalence of PAD that has not been the specific subject of previous randomized prospective studies.

Treatment of Arteriovenous Malformations Involving the Hand - Corrected Proof

2012-01-23

Background: Hand arteriovenous malformations (AVMs) are difficult to treat because of the necessity to maintain function and the high complication rate of treatment. The purpose of this study was to review the treatment of hand AVMs with embolo/sclerotherapy and the surgical procedures at a single institute.Material and Methods: We retrospectively reviewed the medical records and identified the patients who were referred to the vascular division owing to hand AVMs between 1995 and 2009. The lesions were classified according to their affected areas. The treatments used at the clinic included conservative treatment, amputation, and embolo/sclerotherapy. We investigated the clinical data and assessed the treatment results.Results: Sixty-four patients were involved in this study. The median follow-up duration was 26.9 months (range: 3.5–141.8 months). The median age of the patients was 31.5 years (range: 0.3–75.0 years). All of the lesions were of the extratruncal (ET) form, and 37 cases (57.8%) were of the infiltrating type. Sixteen patients were treated conservatively. Primary amputation was performed in seven cases with previous complications such as ulcer, bleeding, or functional limitations. Embolo/sclerotherapy with ethanol was performed in 41 patients. Sixteen (39.0%) of them showed clinical improvement. The treatment of 20 (48.8%) of the 41 patients was interrupted owing to a variety of complications, and 2 (4.9%) of these patients failed with embolo/sclerotherapy. Skin necrosis was the major complication, and this occurred in 17 patients treated with embolo/sclerotherapy—14 of these cases were small and the skin necrosis healed with conservative treatment; 1 patient had autoamputation owing to necrosis; and 2 patients underwent amputation surgery owing to gangrene. The risk for skin necrosis was higher for the AVMs that involved the subcutaneous layer and the AVMs that extended diffusely (P = 0.021, P = 0.011). Seven neuropathic complications developed after embolo/sclerotherapy, and all of them were transient.Conclusions: The symptoms and characteristics of the lesions are important factors in devising a treatment plan for AVMs. AVM treatment, and especially embolo/sclerotherapy, is a long-term prospect, and it carries a potential risk for serious complications. After every treatment, the lesions must be reevaluated and new treatment plans must be made by the members of a multidisciplinary team.

A Positron Emission Tomography/Computed Tomography (PET/CT) Evaluation of Asymptomatic Abdominal Aortic Aneurysms: Another Point of View - Corrected Proof

2011-12-26

Background: To assess the prevalence of increased 18F-fluorodeoxyglucose (FDG) uptake in aneurysmal walls, adopting a case–control approach in a population of asymptomatic patients with abdominal aortic aneurysm (AAA).Methods: This study included 40 males (mean age: 74 years, range: 59–93 years), consecutive, white Caucasian patients, with asymptomatic infrarenal AAA. The mean diameter of AAA was 4.9 cm (range: 4.8–5.4 cm), detected by computed tomography (CT) scan. Control Subjects: 44 age-matched controls subjects (mean age: 71 years, range: 59–85 years, 24 males, 20 females) who were selected according to a case–control criterion among a population of patients without any clinical evidence of atherosclerotic disease. Patients and controls underwent simultaneous FDG-positron emission tomography (PET) and CT imaging from the skull base to the femoral neck by using an integrated PET/CT scanner. PET/CT studies were analysed both visually and quantitatively. For quantitative analysis, circular CT-based regions of interest (ROIs) were drawn on the AAA, on all the aortic segments, and on the large vessel included in the study (carotid, subclavian, and iliac arteries). FDG uptake was quantified by calculating the mean and maximum standardized uptake values (SUVs) within each ROI and normalizing for the blood-pool SUV to obtain the final target-to-background ratio. Arterial calcium load was graded according to a semiquantitative five-point scale based on calcification of the arterial ring.Results: Metabolic activity in the aneurysmal aortic segment was even lower with respect to both the adjacent—nonaneurysmal—samples of patient group and the corresponding arterial segments of control subjects (P < 0.001 and P < 0.01, respectively). In visual analysis, no patients showed an increased focal uptake of degree adequate to identify the aneurysmal arterial wall. AAA patients showed significantly higher values of total calcium load (ACL) than controls in ascending aorta and subclavian and iliac arteries (P < 0.01), and only in AAA patient group, a significant correlation was present between values of ACL in both iliac arteries and abdominal aorta on one side and wall metabolic activity in the same arteries on the other (P < 0.05).Conclusions: In conclusion, our results suggest that FDG hot spot, as well an increased diffuse uptake of FDG, in PET/CT studies is an extremely rare finding in patients with AAA of diameter close to surgical indications.

Paradoxical Pulmonary Embolism With Spontaneous Aortocaval Fistula - Corrected Proof

2011-12-23

Background: Paradoxical pulmonary embolisms are uncommon emergencies and can occur as a consequence of an aortocaval fistula due to unrecognized dislodgement of thrombus from aortic sac into pulmonary circulation. This study reviewed current literature and therapeutic options in this emergency condition requiring prompt management and repair.Methods: Literature was systematically searched for paradoxical pulmonary embolism associated with aortocaval rupture.Results: Eight published cases were identified. However, many other paradoxical pulmonary emboli could have remained undiagnosed due to challenging clinical presentation. Symptoms of high-output cardiac failure and respiratory distress in the presence of large aortoiliac aneurysm and venous hypertension are findings of a possible major abdominal arteriovenous fistula with paradoxical pulmonary embolism. Successful treatment depends on prevention of new embolism and proper management of perioperative hemodynamics and massive bleeding during fistula repair. Endovascular procedures have been recently used as useful tools in this field. Cava filter placement may be a first step to prevent further thrombus dislodgements during aortocaval repair. Immediate subsequent aortic stent–grafting can allow repair of aortocaval communication and exclusion of the abdominal aortic aneurysm from circulation with successful reversal of altered hemodynamic features. However, experience (especially in the long-term) is limited.Conclusions: Paradoxical pulmonary embolism from aortocaval fistula represents an extremely rare but true clinical emergency with high fatality rate. Recent advances in diagnostic technology and endovascular techniques can substantially improve outcomes of the disease. Clinical competence in early detection and diagnosis is essential for appropriate emergent management.

Renal Function in Patients Treated With Abdominal Aortic Stentgraft Implantation With an Intentional Occlusion of Accessory Renal Artery - Corrected Proof

2011-12-21

Background: The purpose of this study was to analyze renal function in patients who underwent endovascular aneurysm repair with intentional occlusion of accessory renal artery (ARA).Material and Methods: A prospective study of six patients with abdominal aortic aneurysm who underwent an abdominal stentgraft implantation with intentional occlusion of at least one ARA was performed. The mean age of the patients was 71 (53–84) years. None of the patients had an estimated glomerular filtration rate (according to Modification of Diet in Renal Disease equation 4) lower than 60 mL/min/m2. Before the intervention, a possible influence of the occlusion of ARA was assessed with a renal scintigraphy and percentage value of a renal mass at risk. After the intervention, a control renal scintigraphy was performed, and percentage value of lost renal mass was determined. Data on the renal function before the intervention and 1, 3, 10, 30, and 90 days after the intervention were collected.Results: There were no deaths, and none of the patients required hemodialysis in the follow-up period. In an early postoperative period, five patients had pain in the lumbar region that ceased with analgesics. An increase of the serum creatinine concentration occurred between 24 and 72 hours after the procedure and, except for 1 patient, started to decrease thereafter. After 30 and 90 days, all the patients presented serum creatinine concentrations similar to the basal values. The mean value of renal mass at risk was 18.5% (13.5–26%), and the mean value of lost renal mass was 18.4% (9.6–22.5%).Conclusion: The endovascular aneurysm repair with an intentional occlusion of ARA is a safe therapeutic option of treatment of abdominal aortic aneurysm in the patients without preexisting renal disease. The renal scintigraphy seems to be useful in determining loss of functional renal mass.

Open Surgical Repair of Thoracoabdominal Aortic Aneurysms - Corrected Proof

Michele Piazza, Joseph J. Ricotta — 2011-12-21

Despite much advancement in preoperative evaluation and perioperative care of patients with thoracoabdominal aortic aneurysms (TAAA), open surgical repair of TAAAs remains a formidable challenge for the vascular surgeon. It requires extensive dissection and mobilization of the aorta and its branches, as well as cross-clamping of the aorta above intercostal and visceral arteries. Over the past decade, the mortality and morbidity associated with open TAAA repair have improved significantly. However, it remains one of the most complex, extensive surgical procedures performed in the field of vascular surgery. Recently, there has been much attention directed at less invasive methods such as the so-called “hybrid” or “debranching” procedure, or complete endovascular repair with fenestrated and branched endografts for repairing TAAAs. However, the gold standard for repair of TAAA remains open surgery, and this article summarizes the clinical outcomes of open surgical repair of TAAAs during the past decade (2000–2010) to provide a benchmark for comparison with results from previous decades and also with which to compare the results of modern-day hybrid and/or complete endovascular techniques.

Socioeconomic Position, Comorbidity, and Mortality in Aortic Aneurysms: A 13-Year Prospective Cohort Study - Corrected Proof

Tomas Ohrlander, Juan Merlo, Henrik Ohlsson, Björn Sonesson, Stefan Acosta — 2011-11-14

Background: To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register.Methods: We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA.Results: We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA.Conclusions: Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA.

An Interdisciplinary Approach to the Prevention and Treatment of Groin Wound Complications After Lower Extremity Revascularization - Corrected Proof

Alyssa J. Reiffel, Peter W. Henderson, John K. Karwowski, Jason A. Spector — 2011-11-07

Background: If not effectively treated, groin wound infections following lower extremity revascularization (LER) may result in graft or limb loss.Methods: A retrospective review was performed of all patients who underwent muscle flap transposition by a single surgeon after LER between 2006 and 2010.Results: Twenty-nine muscle transposition flaps were performed in 24 patients (21 sartorius, 6 rectus femoris, and 2 gracilis). Nineteen were for treatment of groin wound infections, two for treatment of lymphocele, one for coverage of exposed graft in the setting of pyoderma gangrenosum, and seven for infection prophylaxis. Two graft losses followed flap placement. The limb loss rate was 4%. When performed for therapeutic purposes, graft salvage rates were 100% for autogenous and 92% for synthetic grafts.Conclusions: Muscle transposition flaps are an effective means of graft salvage in the setting of groin wound complications following LER and should be considered for infection prophylaxis in high-risk patients.

Quality of Life in Perspective to Treatment of Postoperative Edema After Peripheral Bypass Surgery - Corrected Proof

2011-11-07

Background: To examine the effects of peripheral bypass surgery on patients’ quality of life (QoL) as well as to compare two treatment modalities to reduce postoperative edema with regard to patients’ QoL.Methods: This was a randomized controlled trial set in the department of vascular surgery in a nonacademic teaching hospital. Ninety-three patients (mean age, 70 years; 33% Rutherford 5-6), enrolled between August 2006 and September 2009, who underwent peripheral bypass surgery (autologous 57, polytetrafluoroethylene 36). Patients were assigned to intermittent pneumatic compression (n = 46) or to compression stockings (n = 47). The main outcome measure was QoL, measured with the World Health Organization Quality of Life assessment instrument (short form: WHOQOL-BREF).Results: QoL improved on the domain of Physical Health by 7.18 points (p < 0.001 [range, 0-100]) after 2 weeks and by 10.03 points (p < 0.001) after 3 months. Patients who received a polytetrafluoroethylene bypass scored 0.45 points (p = 0.0008 [range, 1-5]) lower at baseline on Global QoL than patients who received an autologous bypass. Type of bypass or edema treatment method did not affect the improvements. Edema did not correlate with QoL.Conclusion: Improvement in QoL on the domain Physical Health following femoropopliteal bypass surgery was found as soon as 2 weeks after surgery. Improvement in QoL domains was not influenced by the type of bypass reconstruction. No specific effects of edema on QoL were detected.

Femorofemoral Bypass as an Alternative to a Direct Aortic Approach in Daily Practice: Appraisal of its Current Indications and Midterm Results - Corrected Proof

2011-11-02

Background: To assess our current practice concerning the indications and the immediate and midterm results of femorofemoral bypass.Methods: We retrospectively included all patients, from 1997 to 2008, operated on for aortoiliac occlusive disease using an extra-anatomical bypass from a donor iliac artery or a femoral artery to the contralateral femoral artery (common or profunda artery). Demographic data, initial clinical status, characteristics of the interventions, and short- and midterm results were collected. Elective surgery was distinguished from urgent surgery (critical limb ischemia, acute ischemia, vascular infection).Results: One hundred twenty-four femorofemoral bypasses were performed (103 male), mean age 68 (±12) years. Indications were critical limb ischemia (47.1%), intermittent claudication (38.8%), acute ischemia (12.1%), and vascular infections (1.7%). Perioperative outcomes were 5.6% mortality (elective surgery 0.0%, urgent surgery 9.7%, p = 0.02) and 27.4% morbidity without any secondary graft infections (elective surgery 22.5%, urgent surgery 31.9%, p = 0.17). Mean follow-up period was 3 years, and overall survival was 69.4% (elective surgery 88.7%, urgent surgery 56.7%, p = 0.08). At 3 years, primary patency was 81.8% and secondary patency was 89.3% (elective surgery 96.4%, urgent surgery 84.2%, p = 0.68). No significant risk factors for immediate and secondary thromboses were found.Conclusion: In our current practice, femorofemoral bypasses are applied mainly for urgent procedures when avoiding a direct aortic approach is mandatory, with good midterm results. Although indications are limited for good-fit patients, femorofemoral bypass has confirmed safety (no perioperative deaths, no infections) and high durability (good secondary patency).

Lower-Limb Ischemia in the Young Patient: Management Strategies in an Endovascular Era - Corrected Proof

2011-11-02

Background: The aim of this paper is to review the potential role of endovascular interventions for young patients with lower-limb ischaemia.Methods: A literature search was performed of PubMed and Medline databases using appropriate search terms and limits. Case reports, retrospective studies, and prospective studies evaluating treatment of lower-limb ischemia in patients aged <50 years were scrutinized. Articles published between 1966 and 2010 were included in this review.Results: Premature atherosclerosis is likely to represent the commonest cause of lower-limb ischemia in patients aged <50 years, although the incidence of nonatherosclerotic causes such as popliteal entrapment syndrome, cystic adventitial disease, and arteritis in these patients is greater than in older patients. As with older patients, endovascular interventions may be beneficial for patients with symptoms secondary to atherosclerosis. At present, the perceived durability of open surgery may be more preferable to patients aged <50 years, but the development of new endovascular technology is challenging this view. Endovascular interventions such as catheter-directed thrombolysis have specific roles in the treatment of lower-limb ischemia due to nonatherosclerotic causes.Conclusion: The use of angioplasty and stenting procedures to treat young patients with lower-limb ischemia is increasing and has specific roles. However, many developmental causes and nonatherosclerotic conditions still require primary surgical correction.

Endovascular Treatment for Acute Aortic Syndrome - Corrected Proof

2011-11-02

Background: The term “acute aortic syndrome” (AAS) includes conditions of high mortality, such as ruptured aneurysm, pseudoaneurysm and, aortic dissection. Open surgery for these cases has demonstrated unsatisfactory results, and endovascular treatment has become an excellent alternative.Methods: We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period.Results: Sixteen patients underwent endovascular treatment: eight ruptured aneurysms, six aortic dissections, one nonruptured painful aneurysm, and one pseudoaneurysm. No intramural hematoma or penetrating atherosclerotic ulcer was found. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities. Technical success rate was 93%, and overall 30-day mortality was 6.25%.Conclusion: Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has became the main technique for AAS in our hospital.

Successful Embolization of a Suprascapular Artery Aneurysm - Corrected Proof

Federico Bucci, Plagnol P, Salvati B, Capoano R, Fiengo L, Redler A — 2011-05-27

A 45-year-old woman was referred to our service because 9 months earlier she had developed a pulsating mass on the right supraclavicular fossa and torticollis. Ultrasounds and computed tomographic arteriography showed the presence of a subclavian collateral artery aneurysm with a diameter of 21 mm. On selective arteriography, an aneurysm of a suprascapular artery arising directly from the right subclavian artery was reported. The presence of thoracic outlet syndrome was excluded. The aneurysm was successfully treated with ethylene-vinyl alcohol polymer, a liquid embolic agent. The patient was discharged on postoperative day 1 in good general condition. After 12 months, control ultrasounds confirmed the complete thrombosis of the aneurysm sac.

WITHDRAWN: Catheter-Directed Thrombolysis for Acute Iliofemoral Deep Venous Thrombosis - Corrected Proof

Fang Liu, Ping Lü, Bi Jin — 2010-04-05

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy

WITHDRAWN: Carotid Artery Stenting - Corrected Proof

David Paul Slovut — 2009-12-25

WITHDRAWN: Immediate and mid-term results following hybrid procedures for the treatment of thoracoabdominal aneurysms (TAAA) and secondary expanding aortic dissections (SED) - Corrected Proof

2008-09-10

This article has been withdrawn at the request of the Editor-in-Chief. The publisher apologizes for any inconvenience this may cause.