Journal of Vascular Surgery

Cyber medicine enables remote neuromonitoring during aortic surgery

2012-02-17

Objective: This study assessed the feasibility and effectiveness of remote neuromonitoring as an adjunct to spinal cord protection during surgical repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. Methods: Four aortic centers in three European countries participated in this prospective observational study. A similar surgical protocol was used in all centers, including assessment of spinal cord function by means of monitoring motor-evoked potentials (MEPs). MEP information was evaluated at one central neurophysiologic department in Maastricht, The Netherlands. Transfer of MEP data from all operating rooms to Maastricht was arranged by Internet connections. In all patients, the protective and surgical strategies to prevent paraplegia were based on MEPs. The on-site surgeons reacted in real time to the interpretation and feedback of the neurophysiologist. Results: Between March 2009 and May 2011, 130 patients (85 men) were treated by open surgical repair. Extent of aneurysms was equally distributed among the centers. Neuromonitoring was technically stabile and successful in all patients. The transfer of data from the operating room in the different vascular centers was undisturbed and without any technical problems. By maintaining a mean distal aortic pressure of 60 mm Hg, MEPs were undisturbed in 65 patients (50%). In another 65 patients (50%), significant changes in MEPs prompted the surgical teams to initiate additional protective and surgical strategies to restore spinal cord perfusion. These measures were not effective in five patients (3.8%), and acute paraplegia resulted. Delayed paraplegia occurred in 10 patients (7.7%) but improved in three and recovered completely in another three. No false-negative or false-positive MEP recordings were experienced. Conclusions: Remote neuromonitoring of spinal cord function during open repair of descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms as a telemedicine technique is feasible and effective. It allows centralization of expertise and saves individual centers from investing in complex technology. The value of monitoring MEPs was confirmed in different aortic centers, resulting in adequate neurologic outcome after extensive aortic surgical procedures.

Discussion

2012-02-17

Dr Richard Cambria (Boston, Mass). Was there a uniform surgical protocol for how to react to changes in motor-evoked potential monitoring across the four centers? Dr Michael Jacobs. Indeed, all surgeons from the different centers came to us and we agreed on the protocol, including cerebrospinal fluid (CSF) drainage and distal aortic perfusion, but also the strategic interventions when evoked potentials would disappear. The first logical step is to increase mean arterial and distal aortic pressure. The second step includes reattachment of intercostal arteries. Extremely important is that the anesthesiologists are well trained and well informed, because the equilibrium between anesthesia and evoked potentials is extremely sensitive. For example, if the patient receives too much muscle relaxant, evoked potentials are unreliable.

Invited commentary

Manju Kalra — 2012-05-01

Dr Jacobs and his colleagues are to be commended for this first of a kind enterprise using cyber medicine to provide remote neuromonitoring of motor evoked potentials during open thoracoabdominal aortic aneurysm repair. The authors have previously reported extensively on the use of motor evoked potentials as an adjunct for spinal cord protection during these procedures. The complexity, learning curve, and cost have limited the use of this mode of monitoring to a few tertiary centers around the world. With this study, the authors have demonstrated not only the feasibility of a central core center providing this mode of real-time neuromonitoring remotely but also its effectiveness by having achieved similar low rates of spinal cord ischemic complications in the peripheral centers as their own.

Endovascular treatment of acute and chronic aortic pathology in patients with Marfan syndrome

2012-04-02

Background: In patients with Marfan syndrome, the complications of aortic degeneration, including dissection, aneurysm, and rupture represent the main cause of mortality. Although contemporary management of ascending aortic disease requires open surgical reconstruction, endovascular repair is now available for management of descending thoracic and abdominal aortic pathology (ie, thoracic endovascular aortic repair [TEVAR], endovascular aneurysm repair [EVAR]). The short- and long-term benefit of endovascular repair in Marfan patients remains largely unproven. We examine our outcomes after EVAR in this patient population. Methods: All patients with a diagnosis of Marfan syndrome who were treated with TEVAR/EVAR were evaluated in a retrospective review. Perioperative, procedure-specific and patient covariate data were aggregated. Primary endpoints were overall mortality and procedural success as divided into three categories: (1) successful therapy, (2) primary failure, or (3) secondary failure. Results: Between 2000 and June 2010, 16 patients were identified as having undergone 19 TEVAR/EVAR procedures. These included three emergent operations (two for acute dissection/malperfusion and one for anastomotic disruption early after open repair). All 16 patients had previously undergone at least one (range, 1-5) open operation of the ascending aorta or arch at a time interval from 33 years to 1 week prior to the index endovascular repair. During a median follow-up of 9.3 months (range, 0-46 months), there were four deaths (25%). Six patients (38%) had successful endovascular interventions. Despite early success, there was one death in this group at 1 month postintervention. Seven patients (44%) experienced primary treatment failure with five undergoing open conversion and one undergoing left subclavian coil embolization (the seventh was lost to follow-up and presented 4 months later in cardiac arrest and expired without repair). There were three deaths in the primary treatment failure group. Two patients experienced secondary treatment failure. One underwent the index TEVAR for acute dissection with malperfusion and required a subsequent TEVAR for more distal aortic pathology. He is stable without disease progression. The other patient underwent open conversion after a second EVAR with four-vessel “chimney” stent grafts and is stable with his entire native aorta having been replaced. Conclusions: Aortic disease associated with Marfan syndrome is a complex clinical problem and many patients require remedial procedures. Endovascular therapy can provide a useful adjunct or bridge to open surgical treatment in selected patients. However, failure of endovascular therapy is common, and its use should be judicious with close follow-up to avoid delay if open surgical repair is required.

Discussion

2012-04-02

Dr Eric D. Endean (Lexington, Ky). I would like to congratulate the group from the University of Florida for the courage of presenting their results for this difficult problem. The patients presented in this series clearly represent a group for which treatment options are difficult at best. To re-emphasize, 14 of the 16 patients were ASA class IV or IV-E and all were deemed poor candidates for open surgical intervention. Fifteen patients had undergone between one and five previous open aortic operations, averaging almost two open aortic operations per patient. Not unexpectedly, the results are sobering. Four patients died within months of the endovascular procedure and the results in <50% were classified as “successful.” Six patients, or 38%, were classified as primary treatment failures. All patients with treatment failures required an open repair and half of them died. Two patients were felt to have secondary failure, ie, successful treatment of the target pathology, but proximal or distal aortic degeneration requiring further intervention.

Endografts with suprarenal fixation do not perform better than those with infrarenal fixation in the treatment of patients with short straight proximal aortic necks

2012-01-27

Objective: To determine if there are any differences in outcomes between infrarenal fixation (IF) and suprarenal fixation (SF) endograft systems for the endovascular treatment (endovascular aneurysm repair [EVAR]) of abdominal aortic aneurysms (AAAs) with short, straight proximal aortic necks (<1.5 cm). Methods: A retrospective review of 1379 EVAR procedures was performed between the years of 2002 and 2009 at a single institution. The charts and radiographic images of all patients were reviewed. Patients who underwent EVAR with AAA morphology with short proximal necks were stratified into two groups: IF, Gore Excluder (W. L. Gore, Flagstaff, Ariz) group and SF, Cook Zenith (Cook, Bloomington, Ind) group. The primary end point for the study was the presence of proximal type 1 endoleaks. Secondary end points were graft migration at 1- and 2-year follow-up and aneurysm sac regression. The groups' demographics and comorbidities were also compared. Results: A total of 1379 EVARS were performed during the study period and 84 were identified as having a short proximal aortic neck. Sixty patients were in the IF group and 24 in the SF group. The average follow-up period was 18.6 months (IF) and 18.5 months (SF). There was no difference in the average proximal neck length (1.19 cm IF vs 1.14 cm SF; P = not significant [NS]) or the preoperative AAA size (5.8 cm IF vs 5.9 cm SF; P = NS). There were no significant differences in age (76.6 years IF vs 74.8 years SF; P = .32), gender (IF 66.7% vs SF 21.88% men; P = .053), or length of stay (2.2 days IF vs 1.9 days SF; P = .39). The comorbidities (diabetes, hypertension, and warfarin use) were also similar. There were five type 1a endoleaks in group IF and one in group SF (P = .44) identified at the 1-month follow-up; however, only one patient in the IF group underwent intervention for enlargement of the AAA sac. At 1 year, there was persistence of one type 1a endoleak in both groups, but these were deemed dead-end leaks as they did not fill the sac nor lead to aneurysm growth. There were no migrations (>0.5 cm) noted in either group. Sac regression was observed at an average rate of 0.24 cm/year in the IF group and 0.26 cm/year in the SF group (P = NS). There were no aneurysm ruptures during the study period. Conclusions: There are no significant differences in endograft migration or in the incidence of early and late type 1a endoleaks between endografts that use IF (Gore Excluder) and SF (Cook Zenith) fixation for patients with short aortic necks undergoing EVAR.

Higher mortality in patients hospitalized for acute aortic rupture or dissection during weekends

2012-05-01

Background: The management of acute aortic aneurysm rupture or dissection (AARD) requires specific medical expertise, diagnostic techniques, and therapeutic options, not always available in all hospitals through the entire week. The aim of our study was to evaluate whether an association exists between weekday (WD) or weekend (WE) admission and mortality for patients with ARRD. Methods: Based on the database of routinely collected hospital admissions of the region of Emilia Romagna (RER) of Italy, we examined the discharge sheets of all patients with AARD (January 1999 to December 2009). The risk of in-hospital death was calculated for admissions on the WE compared with the admissions during a WD. Results: The analysis considered 4559 events in 4461 patients. AARD admissions were most frequent on Monday (14.7%) and Friday (14.8%) and less frequent on Saturday (12.6%). The percentage of events admitted on Sunday/holiday was 15.0%, whereas the distribution of death rate with respect to day of admission was significantly different (χ2 = 23.472; P < .001) with the highest frequency peak on Sunday/holiday (17.4%) and the lowest on Tuesday (12.9%). WE admissions were associated with significantly higher in-hospital mortality (43.4%) than WD admissions (36.9%, P < .001). Multivariate regression analysis showed that WE admission was an independent risk factor for increased in-hospital mortality odds ratio 1.318; 95% confidence interval, 1.144-1.517; P < .001). Conclusions: Our findings show that hospitalization for AARD on WE is associated with a significantly higher mortality rate than hospitalization on WD. Further studies are needed to investigate whether ensuring optimal diagnostic and therapeutic approaches during the entire week might improve the overall survival of patients with ARRD.

Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair

2012-01-24

Objective: Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event. Methods: A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables. Results: The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1). Conclusions: rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.

Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion

2012-02-10

Objective: Type II endoleak (T2EL) with aneurysm expansion is believed to place patients at risk for aneurysm-related mortality (ARM). Treatment with glue and/or coil embolization of the aneurysm sac, inferior mesenteric artery (IMA), and lumbar branches via translumbar or transarterial approaches has been utilized to ablate such endoleaks, and thus decrease ARM. We evaluated the midterm results of percutaneous endovascular treatment of T2EL with aneurysm expansion. Methods: Single-institution, 5-year (January 2003 to August 2008) retrospective study of all endovascular interventions for T2EL with sac expansion. Blinded, independent review of all available pre- and post-T2EL intervention computed tomography (CT) scans was performed. Aneurysm sac maximal transverse diameters and aneurysm sac growth rates prior to and following T2EL intervention were analyzed. Results: Forty-two patients (34 male, eight female; mean age, 75) underwent T2EL intervention at 26 ± 20 months after endovascular aneurysm repair (EVAR) and were subsequently followed for 23 ± 20 months. Seven out of 42 patients (17%) underwent repeat T2EL intervention. Interventions included 44 translumbar sac embolizations, and transcatheter embolizations of nine IMAs and seven lumbar/hypogastric arteries. Aneurysm diameter was 6.1 ± 1.6 cm at EVAR, 6.6 ± 1.5 cm at initial T2EL treatment, and 6.9 ± 1.7 cm at last follow-up. There were no significant differences in the rates of aneurysm sac growth pre- and post-T2EL treatment. At last follow-up imaging, recurrent or persistent T2EL was noted in 72% of patients. Of 42 patients, nine (21%) received operative endoluminal correction of occult type I or type III endoleaks that were diagnosed during the T2EL angiographic intervention. There were no aneurysm ruptures or ARMs during follow-up; overall mortality for the 5-year study period was 24%. Conclusions: In this series, percutaneous endovascular intervention for type II endoleak with aneurysm sac growth does not appear to alter the rate of aneurysm sac growth, and the majority of patients display persistent/recurrent endoleak. However, diagnostic angiographic evaluation may reveal unexpected type I and III endoleaks and is therefore recommended for all patients with T2EL and sac growth. While coil and glue embolization of aneurysm sac and selected branch vessels does not appear to yield benefit in our series, the diagnosis and subsequent definitive treatment of previously occult type I and III endoleaks may explain the absence of delayed rupture and ARM in our series.

Invited commentary

Bruce J. Brener — 2012-05-01

This article questions our current assumptions concerning the treatment outcomes of type II endoleaks. While it is generally acknowledged that these leaks occur frequently and are usually merely annoying, the results of treating more pernicious type II endoleaks that are accompanied by sac enlargement are largely unknown. These latter leaks, while rare, are often complicated, involving several sets of lumbar arteries, the inferior mesenteric artery, and extensive collateral networks. It is not surprising that simple embolization of the lumber, mesenteric, or internal iliac branches would not control these leaks. In fact, several groups have pointed this out, recommending translumbar approaches with coils and glue, and insisting on complete obliteration of the leak “nidus” within the sac.

A morphologic study of chronic type B aortic dissections and aneurysms after thoracic endovascular stent grafting

Kai-xiong Qing, Wai-ki Yiu, Stephen W.K. Cheng — 2012-01-18

Background: The long-term results of treating chronic aortic dissections and aneurysms in association with dissections with thoracic endovascular aortic repair (TEVAR) are unknown, and the timing for intervention is uncertain. We evaluated the morphology of stent graft and aorta remodeling and the volumetric changes in these patients after successful TEVAR. Methods: Serial computed tomography scans of 32 patients who underwent TEVAR for uncomplicated chronic dissections (group A, n = 17) and chronic dissections with aneurysms (group B, n = 15) were analyzed at 1, 6, 12, and 36 months. Stent graft diameter changes and positional migration were assessed three-dimensionally using Mimics 14.0 (Materialize, Leuven, Belgium). Volumetric data for true lumen, false lumen, thrombus load, and aortic size were measured by Aquarius iNtuition 4.4 software (TeraRecon, San Mateo, Calif). Results were compared between the two groups and with stent graft diameter, length, and oversizing. Results: Aortic stent grafts remodeled progressively, with inlet area increasing 4.4%, 10.1%, and 14.2% and outlet area increasing 42.6%, 67.2%, and 72.3%, respectively, at 6, 12, and 36 months. True lumen volume increased progressively in group A (114 to 174 mL) and group B (124 to 190 mL) from baseline to 36 months. False lumen volume decreased in group A (150 to 88 mL) and group B (351 to 250 mL), whereas thrombus load in the false lumen increased from 73% to 80% in group A and 84% to 87% in group B in 3 years. Eight patients (4 in each group) showed an increase in total aortic volume of >10%, 12 showed a static volume, and 12 showed shrinkage. Aortic volume change had no relationship to pathology, stent graft sizing, and thrombus load but was positively associated with the placement of a longer graft. A small but progressive distal migration of stent grafts was noted in all patients (3.1, 4.5, and 5.1 mm at 6, 12, and 36 months) but was more prominent in shorter stent grafts (≤162 mm). No deaths, rupture, or secondary interventions occurred during follow-up. Conclusions: Aortic remodeling after TEVAR in chronic dissection is a continuous process. There were no significant differences between chronic dissections and aneurysms in all volumetric parameters. Treating chronic dissections early, before aneurysm formation, did not appear to have a morphologic advantage.

Discussion

2012-01-18

Dr Vincent Rowe (Los Angeles, Calif). Thank you for allowing me to review this interesting manuscript. Dr Cheng and his team from Hong Kong did a magnificent job of detailing changes seen in chronic uncomplicated type B aortic dissections with and without aneurysmal degeneration. The authors utilized CT scans and imaging software to provide volumetric data of the aorta over a 36 month period poststenting. I believe this manuscript holds significant merit because the radiologic findings found in this study may help answer the question as to whether endografting should become the primary treatment for type B aortic dissections. I do have the following questions for the authors:

Blunt abdominal aortic injury

2012-02-10

Background: Blunt abdominal aortic injury (BAAI) is a rare injury with less than 200 cases in the current reported world literature, mostly in case report format. We sought to describe the experience of a high-volume trauma center and to provide a contemporary review of the literature to better understand the natural history and management of this injury. Methods: This was a retrospective review of patients with BAAI between 1996 and 2010. Data collected included demographics, mechanism of injury, associated injuries, type of intervention, subsequent imaging, and follow-up. BAAI was classified by the presence of external aortic contour abnormality noted as an intimal tear, large intimal flap, pseudoaneurysm, or free rupture. Abdominal aorta zones of injury were classified by possible surgical approaches as zone I (diaphragmatic hiatus to superior mesenteric artery [SMA]), zone II (includes SMA and renal arteries), and zone III (from the inferior aspect of the renal arteries to the aortic bifurcation). Results: We identified 28 individuals (68% male) with BAAI (median age, 28.5; range, 6-61 years). The median injury severity score was 45 (range, 16-75), and 39% were hypotensive at presentation. BAAI presented as intimal tear (21%), large intimal flap (39%), pseudoaneurysm (11%), and free rupture (29%). Zone III was the most common location of injury. Management depended on the location and type of injury: nonoperative (32%), open aortic repair (36%), endovascular repair (21%), and multimodality (10%). Overall mortality was 32%. Most deaths occurred during the initial operative exploration. The mortality rate of free aortic rupture was 100%. Intimal tears resolved or remained stable. Median follow-up was 15.5 months (range, 8 days-7.5 years). Vascular complications due to repair included a thrombosed access femoral artery during an endovascular repair and death of a patient who underwent a hybrid repair. Conclusions: This is the largest BAAI series described in the English literature at one institution. BAAIs range from intimal tears to free rupture, with outcomes and management correlating with type and location of injury. Nonoperative management with blood pressure control using β-blockers coupled with antiplatelet therapy and close follow-up is successful in individuals with intimal tears with minimal thrombus formation because they remain stable or resolve on follow-up. Free rupture remains a devastating injury, with 100% mortality. For all other categories of aortic injury, successful repair correlates with a favorable prognosis.

Invited commentary

John F. Eidt — 2012-05-01

Shalhub et al have described the treatment of blunt abdominal aortic injuries at one of the major trauma centers in the country. Fortunately, this is an exceedingly rare injury with which few surgeons will ever develop significant personal experience. From a trauma population of >37,000 admissions, the authors identified only 28 cases over 15 years. Not surprisingly, free rupture of the abdominal aorta was uniformly fatal, despite heroic and inventive treatments. On the other end of the spectrum, the authors conclude that intervention is unnecessary for many minor aortic injuries that heal spontaneously.

Preoperative predictive factors of aneurysmal regression using the reporting standards for endovascular aortic aneurysm repair

2012-03-30

Background: Aneurysmal regression is a reliable marker for long-lasting success after endovascular aneurysm repair (EVAR). The aim of this study was to identify the preoperative factors that can predictably lead to aneurysmal sac regression after EVAR, according to the reporting standards of the Society for Vascular Surgery and the International Society of Cardiovascular Surgery (SVS/ISCVS). Methods: From 199 patients treated by EVAR between 2000 and 2009, 164 completed computed tomography angiographies and duplex scan follow-up images were available. All computed tomography angiographies for enrolled patients in this retrospective study were analyzed with Endosize software (Therenva, Rennes, France) to provide spatially correct 3-dimensional data in accordance with SVS/ISCVS recommendations. Anatomic parameters were graded according to the relevant severity grades. A severity score was calculated at the aortic neck, the abdominal aortic aneurysm, and the iliac arteries. Clinical and demographic factors were studied. Patients with aneurysmal regression >5 mm were assigned to group A (mean age, 71.4 ± 8.9 years) and the others to group B (76.3 ± 8.3 years). Results: Aneurysmal regression occurred in 66 patients (40.2%; group A). Univariate analyses showed smaller severity scores at the aortic neck (P = .02) and the iliac arteries (P = .002) in group A and calcifications and thrombus were less significant at the aortic neck (P = .003 and P = .02) and at the iliac arteries (P = .001 and P = .02), and inferior mesenteric artery patency was less frequent (68.2% vs 82.7%, P = .04). Two multivariate analyses were done: one considered the scores and the other the variables included in the scores. In the first, the patients of group A were younger (P = .002) and aortic neck calcifications were less significant (P = .007). In the second, group A patients were younger (P < .001) and the aortic neck scores were smaller (P = .04). There was no difference between the two groups in the type of implanted endoprosthesis or in the follow-up (group A: 46.4 ± 24 months; group B: 47.2 ± 22 months; P = .35). Conclusions: In this study, the young age of the patients and their aortic neck quality, in particular the absence of neck calcification, appear to have been the main factors affecting aneurysm shrinkage, such that they represent a target population for the improvement of EVAR results.

Systematic review of guidelines on abdominal aortic aneurysm screening

2011-02-17

Objective: Usually, physicians base their practice on guidelines, but recommendations on the same topic may vary across guidelines. Given the uncertainties regarding abdominal aortic aneurysm (AAA) screening, physicians should be able to identify systematically and transparently developed recommendations. We performed a systematic review of AAA screening guidelines to assist physicians in their choice of recommendations. Methods: Guidelines in English published between January 1, 2003 and February 26, 2010 were retrieved using MEDLINE, CINAHL, the National Guideline Clearinghouse, the National Library for Health, the Canadian Medication Association Infobase, and the G-I-N International Guideline Library. Guidelines developed by national and international medical societies from Western countries, containing recommendations on AAA screening were included. Three reviewers independently assessed rigor of guideline development using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Two independent reviewers performed extraction of recommendations. Results: Of 2415 titles identified, seven guidelines were included in this review. Three guidelines were less rigorously developed based on AGREE scores below 40%. All seven guidelines contained a recommendation for one-time screening of elderly men by ultrasonography to select AAAs ≥5.5 cm for elective surgical repair. Four guidelines, of which three were less rigorously developed, contained disparate recommendations on screening of women and middle-aged men at elevated risk. There was no agreement on the management of smaller AAAs. Conclusions: Consensus exists across guidelines on one-time screening of elderly men to detect and treat AAAs ≥5.5 cm. For other target groups and management of small AAAs, prediction models and cost-effectiveness analyses are needed to provide guidance.

Invited commentary

Elliot L. Chaikof — 2012-05-01

Clinical practice guidelines for the care of a patient with an abdominal aortic aneurysm (AAA) have been published from a variety of sources, including disparate specialty groups and government-sponsored organizations. Although each published guideline is the end result of a comprehensive review of the available clinical evidence, recommendations are often not uniform. In large measure, this reflects a reality in which the evidence for many clinical decisions is lacking or of limited quality and simple rules for weighing the validity of any individual randomized controlled trial or observational study do not exist. As such, expert panels are called upon to assess the available evidence and provide consensus recommendations. Cognitive biases and differences in values are inherent in any set of recommendations, particularly in efforts directed at averting loss of life, weighing the risks and benefits of intervention, and optimizing cost-effective care. Limiting bias, improving the quality of decisions, and enhancing forecasts in a world where information is incomplete is an area of active investigation. In one important effort to address the need for explicit statements of uncertainty in clinical practice guidelines, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was introduced to note the strength of any given recommendation, as well as the quality of the available evidence. Although these and other tools have some value in determining whether a practitioner should adopt a specific guideline, the burden to carefully evaluate both the stated rationale and the related content that forms the basis for the recommendation remains on the clinician. For many areas, particularly where the data may be incomplete, this requires a measure of effort and an appreciation of the unique context of one's practice.

Invited commentary

Ruth L. Bush — 2012-05-01

“Systematic review of guidelines on abdominal aortic aneurysm screening” is a well-written and timely article by Ferket and colleagues. After extensive literature review of guidelines on abdominal aortic aneurysm (AAA) screening, these authors found only seven guidelines that provided consensus recommendations for a one-time screening for (AAA): basically, men age 65 years and older should be screened using duplex ultrasound. However, as they correctly state, 90% of identified AAAs are small (3.0-3.9 cm). Policy makers, Centers for Medicare and Medicaid, and third-party payers need to pay attention to these data. Currently, Medicare allows for a one-time AAA screening in the “Welcome to Medicare” physical, an examination performed within the first 12 months of becoming a Medicare (part B) beneficiary. Unfortunately, this screening test is not always ordered or performed and not all beneficiaries meet the criteria to order the ultrasound, which include family history and smoking.

Class I obesity is paradoxically associated with decreased risk of postoperative stroke after carotid endarterectomy

2012-05-01

Introduction: Although obesity is a risk factor for vascular disease, previous studies have shown an obesity paradox with decreased mortality in obese patients undergoing vascular surgery. This study examined the relationship between body mass index (BMI) and outcomes after carotid endarterectomy (CEA). Methods: The 2005-2009 American College of Surgeons National Surgical Quality Improvement Program database was queried to evaluate 30-day outcomes after isolated CEA across National Institutes of Health-defined obesity classes. χ2 analysis was used to assess the unadjusted relationship of BMI category to postoperative outcomes. The independent association of BMI with morbidity and mortality was assessed with multivariable logistic regression, adjusting for preoperative and operative characteristics. Results: In the cohort of 23,652 CEA, 1.8% of patients were underweight (BMI <18.5), 26.6% were normal weight (BMI 18.5-24.9), 39.4% were overweight (BMI 25.0-29.9), 21.1% were class I obese (BMI 30.0-34.9), 7.5% were class II obese (BMI 35.0-39.9), and 3.5% were class III obese (BMI ≥40). The overall stroke and mortality rates were 1.4% and 0.6%, respectively. On univariable analysis, there were U-shaped relationships between death (P = .017) and stroke (P = .029), with the lowest incidence in overweight and class I obese patients. The incidence of surgical site infection (SSI) (P = .021) increased incrementally with increasing BMI. On multivariable analysis, class I obesity was the only variable associated with decreased risk of stroke (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31-0.83; P = .007). Independent risk factors for stroke were previous transient ischemic attack (OR, 1.97; P = .006), American Society of Anesthesiologists class 4 to 5 (OR, 1.62; P = .010), surgery performed by a nonvascular surgeon (OR, 1.85; P = .015), and hemiplegia (OR, 1.97; P = .018). There was also a trend, although not statistically significant, toward decreased mortality risk associated with class I obesity (OR, 0.53; 95% CI, .26-1.08; P = .080). Class II obesity was associated with an increased risk of SSI compared with normal weight (OR, 2.21; 95% CI, 1.01-4.82; P = .047). BMI category was not associated with the risk of myocardial infarction. Conclusions: An obesity paradox exists for stroke and mortality after CEA; for stroke, but not mortality, this protective association was independent of patient demographics and comorbidities. Obesity is not a contraindication to CEA, and surgeons may safely undertake CEA in obese patients when indicated.

Society for Vascular Surgery (SVS) Vascular Registry evaluation of comparative effectiveness of carotid revascularization procedures stratified by Medicare age

2012-03-30

Objective: Recent randomized controlled trials have shown that age significantly affects the outcome of carotid revascularization procedures. This study used data from the Society for Vascular Surgery Vascular Registry (VR) to report the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS). Methods: VR collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary end point was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days. Results: As of December 7, 2010, there were 1347 CEA and 861 CAS patients aged <65 years and 4169 CEA and 2536 CAS patients aged ≥65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities. In patients aged <65 years, the primary end point (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.10%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6.00% vs 5.47%; P = .79) group. In patients aged ≥65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥65 years was associated with lower rates of the primary end point in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, CAS patients aged ≥65 years were more likely to reach the primary end point. Conclusions: Compared with CEA, CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥65 years. These findings do not support the widespread use of CAS in patients aged ≥65 years.

Discussion

2012-03-30

Dr Joseph Hart (Charleston, SC). I congratulate the authors on a great study and a very complete manuscript with an enormous amount of data. Thank you. They looked at approximately 9000 carotid revascularization procedures and stratified them by age from the Society for Vascular Surgery Vascular Registry. It appears to be, again, a large, rigorously analyzed study with the stated limitations that the authors have mentioned.

Changes in baroreceptor sensitivity after eversion carotid endarterectomy

2012-03-29

Objective: Posteversion carotid endarterectomy hypertension has been suggested to be associated with impaired baroreceptor sensitivity (BRS), which has been identified as a factor of prognostic relevance in patients with cardiovascular disease. The aim of this prospective single-center nonrandomized study was to describe the changes of BRS in the early postoperative period after eversion carotid endarterectomy (E-CEA). Methods: Spontaneous BRS and hemodynamic parameters such as blood pressure (BP), heart rate (HR), cardiac output (CO), and total peripheral resistance (TPR) were evaluated preoperatively as well as postoperatively after 1 and 3 days using a noninvasive sequential cross-correlation method. Additionally, any modification in vasoactive medication due to BP derangement in the postoperative period was noted. Due to non-normal distribution of BRS, HR, and TPR samples, all measured values were expressed as medians with interquartile range (IQR), and a nonparametric test (Friedman) was performed. After adjustment for multiple testing, differences were considered statistically significant when the two-tailed P value was less than .0036. Results: Thirty-five patients (mean age, 71 years) with symptomatic or asymptomatic internal carotid artery stenosis were included. The BRS significantly decreased to a lower level 24 hours after surgery (4.71 ms/mm Hg [3.02-6.1]) than preoperatively (5.95 ms/mm Hg [4.68-10.86]; P < .0001), resulting in a within-patient difference of –2.46 ms/mm Hg (95% confidence interval [CI], –8.38 - –1.52). This difference (95% CI, [– 1.58 (–8.24 - –0.80)]) persisted at the 72-hour measurements (5.63 ms/mm Hg [3.23-7.69]; P = .0005). The HR, reflecting the sympathetic activity, increased 24 hours after the operation (69 bpm [61.3-77.7]) compared with preoperative values (63 bpm [57.9-73.2]; P = .005) (within-patient difference [95% CI] 3.7 [1.5-8.5]), and this increase reached significance at 72 hours (69 bpm [65.4-77.5]; P = .001) (within-patient difference [95% CI] 5.5 [2.3-8.8]). Values of systolic pressure, diastolic pressure, mean arterial pressure, CO, and TPR were not significantly different between pre- and postoperative measurements. Overall, 23 (66%) patients developed significant postoperative hypertension requiring aggressive management with additional medications. Conclusions: E-CEA might have a decreasing influence on BRS, leading to increased sympathetic activity. Investigations of the longer-term effects of impaired BRS are warranted. These findings should be interpreted with caution, noting the limitation of an absent control group.

Diagnosis and management of evacuated casualties with cervical vascular injuries resulting from combat-related explosive blasts

Colin A. Meghoo, James W. Dennis, Caroline Tuman, Raymond Fang — 2012-02-10

Background: Explosive blasts are common in the modern military environment. These blasts incorporate a concussive component (primary blast injury) and a penetrating component (secondary blast injury). Penetrating injuries are the leading cause of death and injury in these attacks. This review characterizes the vascular injuries associated with penetrating blast injuries to the neck and provides recommendations on the early management of these casualties for the surgeon unfamiliar with these injuries. Methods: The Landstuhl Regional Medical Center Trauma Registry was queried for admissions from January 1, 2006, to June 30, 2010, coded for a penetrating injury to the neck caused by a blast mechanism. Medical records were abstracted from the patient's initial presentation and care through the deployed military medical system. We recorded the vascular injuries, diagnostic studies, operative events, and early postinjury course for all identified patients. Results: Query of the Landstuhl Regional Medical Center Trauma Registry initially identified 252 patients, of which 53 were excluded because their injuries arose from other mechanisms or were only superficial. Among the remaining 199 patients, 38 (19.1%) sustained 44 vascular injuries requiring treatment. Compelling physical examination findings (“hard signs”) were present in 15 (7.5%), who underwent immediate neck exploration. Another 12 patients also underwent neck exploration without any prior imaging studies. Computed tomography (CT) or CT angiography (CTA) examinations were done in 172 patients without hard-sign physical examination findings. Of these, the result of the imaging study was negative in 106 patients, and no further investigation or treatment for cervical vascular trauma was initiated. Of 66 patients who underwent CT/CTA before operative neck exploration, CT/CTA identified a vascular injury in 26 that was later confirmed on neck exploration. The combination of physical examination and CT/CTA resulted in a sensitivity of 96.3% and a specificity of 97.2% in diagnosing cervical vascular injury. Conclusions: Penetrating cervical wounds from war-related blast trauma are associated with potentially life-threatening vascular injuries. The presenting physical examination, availability of CT/CTA, local surgical expertise, and tactical combat situation all contribute to surgical decision making in these patients. In patients without hard signs of vascular trauma and a normal CT/CTA of the neck, there is no evidence to support mandatory surgical neck explorations or further immediate diagnostic studies to exclude cervical vascular injury.

Discussion

2012-02-10

Dr Karen Woo (Los Angeles, Calif). Thank you to the committee for allowing me to review this paper. Dr Fang and colleagues have written an excellent review of the evaluation and management of patients with penetrating neck injury in the setting of combat. I believe these results are important in that they represent a mechanism of injury that is somewhat different from what we normally see in the civilian population. They found that their results primarily validate the current civilian practice of a management algorithm based on physical examination findings and CT angiogram results.

Results of external iliac artery reconstruction in avid cyclists

2012-03-29

Objective: We report the midterm results of external iliac artery reconstruction in 25 high-performance cyclists. Methods: Cyclists undergoing arterial reconstruction for symptomatic external iliac arteriopathy at a single institution between October 2004 and August 2010 were identified. With Institutional Review Board approval, data were collected from medical record review and telephone interview. Results were analyzed with χ2 or independent t-test. Results: Twenty-five patients (31 limbs) underwent operation, which included arterial reconstruction with or without inguinal ligament release. The average patient age at operation was 43.8 ± 5.0 for graft and 35.1 ± 1.9 for patch (P = .08). The average time from competitive cycling until operation was 18.2 ± 5.8 years for graft and 20.0 ± 2.5 for patch repairs (NS). Patients included 14 males and 11 females. There were 23 unilateral and four bilateral arterial reconstructions, including 26 patch angioplasties for localized disease and five interposition grafts for extensive disease; three patients underwent contralateral reconstruction as a separate procedure. Concomitant ipsilateral inguinal ligament release was performed in 25 patients (28 limbs), with contralateral release done in 12 patients (12 limbs). Three patients with isolated ligament release required subsequent arterial intervention. Follow-up averaged 32 months (range, 2-74). Primary patency for all reconstructions was 100%; the four reoperations (five limbs; one bilateral) were for symptom recurrence, two postgraft and two postangioplasty. Three reoperations were for recurrent intimal hyperplasia, one for disease distal to the anastomosis, and one for concomitant atherosclerotic disease. Based on available data, postexercise ankle-brachial indices were improved in 18 of 23 limbs. Seventeen patients completed questions regarding satisfaction: 10 were satisfied or very satisfied (zero graft, 10 patch; P = .25), while four were unsatisfied (three graft, two patch; P = .017, including one patient with both a patch and graft repair). All 20 patients for whom follow-up data were available are still cycling, 10 competitively. Two of the four reoperated patients were unsatisfied; all four are still cycling, one competitively. Conclusions: External iliac arteriopathy is a disease of prolonged, sustained, and repetitive trauma. Patch angioplasty yields a low rate of reoperation, more satisfied patients, return to competitive activity, and improvement in postexercise ankle-brachial indices. Interposition grafting is associated with slightly older patients, more extensive disease, and less satisfying results. Intimal hyperplasia is the most frequent complication necessitating reoperation. Both the decision to pursue arterial reconstruction and patient expectations must be tempered by the pattern of disease and the potential for unsatisfactory results.

Discussion

2012-03-29

Dr Jonathan Beard (Sheffield, United Kingdom). Did you have any patients that required shortening of the external iliac artery? We find that once you have freed up the artery, it is often tortuous and you have to shorten it a bit.

Optimal exercise program length for patients with claudication

Andrew W. Gardner, Polly S. Montgomery, Donald E. Parker — 2012-03-29

Background: This prospective, randomized controlled clinical trial determined whether an optimal exercise program length exists to efficaciously change claudication onset time (COT) and peak walking time (PWT) in patients with peripheral artery disease and claudication. Methods: The study randomized 142 patients to supervised exercise (n = 106) or a usual care control group (n = 36), with 80 completing the exercise program and 27 completing the control intervention. The exercise program consisted of intermittent walking to nearly maximal claudication pain 3 days per week. COT and PWT were the primary outcomes obtained from a treadmill exercise test at baseline and bimonthly during the study. Results: After exercise, changes in COT (P < .001) and PWT (P < .001) were consistently greater than changes after the control intervention. In the exercise program, COT and PWT increased from baseline to month 2 (P < .05) and from months 2 to 4 (P < .05) but did not significantly change from months 4 to 6 (P > .05). When changes were expressed per mile walked during the first 2 months, middle 2 months, and final 2 months of exercise, COT and PWT only increased during the first 2 months (P < .05). Conclusions: Exercise-mediated gains in COT and PWT occur rapidly within the first 2 months of exercise rehabilitation and are maintained with further training. The clinical significance is that a relatively short 2-month exercise program may be preferred to a longer program to treat claudication because adherence is higher, costs associated with personnel and use of facilities are lower per patient, and more patients can be trained for a given amount of personnel time and resource utilization.

Adjunctive use of the superficial femoral vein for vascular reconstructions

Soma Brahmanandam, Daniel Clair, James Bena, Timur Sarac — 2012-03-29

Objective: Although the superficial femoral vein (SFV) is an accepted treatment for aortic graft infections, this conduit also has potential uses in other areas. Herein, we evaluate our experience using the SFV for arterial and venous bypasses and the arteriovenous (AV) fistula for dialysis access. Methods: Between 1999 and 2011, 42 patients underwent a bypass or a thigh AV fistula using the SFV (31 arterial, four central venous, six AV fistulas, and one common carotid-to-vertebral bypass). Indications for arterial bypass included infected graft (20), critical limb ischemia (nine), and failed bypass (six). Indications for central venous bypass were: superior vena cava syndrome (two), vessel reconstruction due to tumor encasement (one), and central vein occlusion from thoracic outlet syndrome (one). All AV fistulas were created after patients sustained bilateral subclavian vein occlusions from failed upper extremity access. The common carotid-to-vertebral bypass was created due to an occluded vertebral artery with resultant stroke. Results: Kaplan-Meier cumulative patency curves were used. The primary patency rates at 30 days, 1 year, and 3 years were 97.4% (95% confidence interval [CI], 92.41-100), 74.6% (95% CI, 57.89-96.23), and 66.4% (95% CI, 47.06-93.53), respectively. The assisted primary patency rates at 30 days, 1 year, and 3 years were 100% (95% CI, 100-100), 97.1% (95% CI, 91.54-100), and 89% (95% CI, 74.29-100), respectively. Secondary patency rates at 30 days, 1 year, and 3 years were 100% (95% CI, 100-100), 97.1% (95% CI, 91.54-100), and 89% (95% CI, 74.29-100), respectively. Limb salvage rates at 30 days, 1 year, and 3 years were 97.3% (95% CI, 92.21-100), 93.6% (95% CI, 78.35-100), and 93.6% (95% CI, 78.35-100), respectively. Survival rates at 30 days, 1 year, and 3 years were 97.6% (95% CI, 92.95-100), 86% (95% CI, 75.3-98.3), and 86% (95% CI, 75.3-98.3), respectively. Follow-up ranged from 1 month to 8.7 years (mean time, 21 months). Complications occurred in 22 patients (52%) and included wound complications (n = 19; 45.2%); deep vein thrombosis (n = 1; 2.4%); anastomotic breakdown (n = 1; 2.4%); hematoma (n = 4; 9.5%); pulmonary embolism (n = 2; 4.8%); and compartment syndrome (n = 2; 4.8%). Conclusions: The SFV is a durable conduit for uses beyond aortic reconstruction and should be considered when the great saphenous vein is not available or size match is a concern. However, wound complications remain a problem.

Costochondral calcification, osteophytic degeneration, and occult first rib fractures in patients with venous thoracic outlet syndrome

2012-02-10

Objective: Subclavian vein (SCV) compression in venous thoracic outlet syndrome (TOS) has been attributed to various anatomic factors, but a potential role for costochondral degeneration in the underlying first rib has not been previously examined. The purpose of this study was to examine the frequency of costochondral calcification (CC), osteophytic degeneration (OD), and occult first rib fractures (FRFx) in patients with venous TOS. Methods: Thirty-seven patients (21 male, 16 female) were referred for surgical treatment of venous TOS during a 12-month period, with a mean age of 30.7 ± 1.8 year (range, 12-55). Thirteen (35%) had acute SCV effort thrombosis and 24 (65%) had chronic symptoms (>14 days). Twenty (54%) had undergone SCV thrombolysis, 11 (30%) had persistent SCV occlusion, and 10 (27%) had concomitant symptoms of neurogenic TOS. All patients underwent paraclavicular thoracic outlet decompression with complete resection of the first rib to the sternum, with 20 (54%) having concomitant SCV reconstruction. The presence or absence of CC, OD, and FRFx was determined by direct visual examination of the rib at operation and following debridement of the excised specimen. Results: One patient had a cervical rib but there were none with radiographic first rib abnormalities. In contrast, FRFx were observed at surgical resection in 16 of 37 patients (43%). All FRFx were small, nondisplaced, linear lesions located within an area of CC in the anterior rib, typically in association with OD and perivenous soft tissue thickening. The mean age of patients with FRFx was higher than those with a normal first rib (38.1 ± 1.5 years vs 25.0 ± 2.3 years; P < .0001), and FRFx were present in 16 of 21 (76%) patients ≥30 years of age but in no patients younger than 30 (P < .0001). Conclusions: A high proportion (43%) of patients with venous TOS exhibited CC, OD, and a previously undetected FRFx, including 76% of those over the age of 30. These lesions occur in the cartilaginous anterior rib where they are clinically occult and undetected by standard radiographic imaging. We postulate that age-related CC may predispose to OD and stress-induced FRFx, and that inflammation, fibrosis, and anatomic distortion in the surrounding soft tissues may contribute to SCV compression.

Impact of anterior scalene lidocaine blocks on predicting surgical success in older patients with neurogenic thoracic outlet syndrome

2012-03-29

Objective: Surgical management of neurogenic thoracic outlet syndrome (NTOS) is controversial due to the lack of predictors of success and difficulties in patient selection. We sought to examine the effects of patient demographics, etiology, duration of symptoms, and the selective use of lidocaine and botulinum toxin anterior scalene blocks on outcomes of patients undergoing transaxillary decompression with first rib resection and scalenotomy for NTOS. Methods: Patients with NTOS who had failed physical therapy and had transaxillary decompression between 2003 and 2009 were reviewed retrospectively from a prospectively maintained database. Patients were stratified to age groups <40 and ≥40 years old. Bivariate and multivariate statistical models of analysis were used. Results: One hundred fifty-nine procedures (16 patients bilateral; three patients with cervical ribs; 84.3% women; median age, 37 years; range, 21-64 years) were identified. Ninety-six patients were <40 and 63 were ≥40 years old. Etiology was similar in both groups: trauma 43% vs 46% and chronic repetitive motion 57% vs 54%. Duration of symptoms was less in the <40 group (38.4 vs 66 months; P < .05). More patients in the ≥40 group had other spine, shoulder, or arm operations (38% vs 18%; P < .05). Median follow-up for the cohort was 12 months. Transaxillary decompression was more likely to relieve symptoms in patients <40 vs ≥40 years old (90% vs 78%; P < .05). Lidocaine blocks were positive in 89% (49 of 55 patients) in the <40 group and 93% (43 of 46 patients) in the ≥40 group. After adjusting for patient presenting factors in multivariate analysis, the impact of a successful lidocaine block in patients ≥40 years old was greater than in patients <40 years old (improvement of surgical success of 14% in the >40 group vs 7% in the <40 group; P = .05). Botulinum toxin blocks were successful in less patients, 38% (eight of 21 patients) in the <40 group and 52% (12 of 23 patients) in the ≥40 group but were not predictive of symptom relief after transaxillary decompression. Conclusions: Although patients with NTOS <40 years old achieve more symptom relief overall after transaxillary decompression as compared to patients ≥40 years old, the selective use of lidocaine blocks is more beneficial in predicting surgical success in patients ≥40 years old given that younger patients <40 years old seem to do well regardless.

Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers

2012-03-19

Background: Compression therapy is not common for venous leg ulcer patients in Hong Kong. Methods: This randomized controlled trial compared the clinical effectiveness of compression bandaging using four-layer bandaging (4LB) or short-stretch bandaging (SSB) and usual care (moist wound healing dressing without compression). The 24-week study looked at venous leg ulcer patients aged >60 years in a community setting. The primary parameter was time to ulcer healing. Secondary parameters were ulcer area and pain reduction comparing week 0 (start) vs week 24 (end), measuring results per group and between groups. Intention-to-treat analysis involved descriptive statistics, survival analysis, and repeated measures analysis of variance. The log-rank test was used for univariable analysis. All withdrawn patients had a negative outcome score over the whole study duration. Results: Of 321 patients who received randomized treatment, 45 (14%) did not complete the 24-week study period. At 24 weeks, Kaplan-Meier analysis on healing time was statistically significant (P < .001) in favor of the compression groups. The mean (SD) healing time in the SSB group (9.9 [0.77]) was shorter than that of the 4LB group (10.4 [0.80]) and the usual care group (18.3 [0.86]). Pain reduction was significant (P < .001) for the compression-treated groups only. Conclusions: Compression bandaging was more effective than usual care without compression. Both compression systems were safe and feasible for venous ulcer patients in a community setting in Hong Kong.

Inferior vena cava resection and reconstruction for retroperitoneal tumor excision

William Quinones-Baldrich, Ali Alktaifi, Fritz Eilber, Frederick Eilber — 2012-03-05

Objective: This study reviews the results of en bloc resection of the inferior vena cava (IVC) for malignant tumor excision and reconstruction. Methods: A prospective database was reviewed. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>one segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, and graft patency were recorded. Results: Between 1990 and 2011, 47 patients (21 women; mean age, 56; range, 35-89 years) underwent IVC resection for en bloc tumor excision. Sarcomas were most common (36 [77%]: 30 primary IVC). Eleven patients had primary IVC repair, nine patch repair (two autogenous), and 27 had circumferential replacement with a polytetrafluoroethylene ringed graft. Extensive IVC reconstruction in 18 patients included the entire IVC, with renal (RV) and hepatic vein reimplantation in eight; suprarenal and perirenal in six (seven RVs reimplanted); and infrarenal and perirenal in four (four RVs reimplanted). Nine single-segment IVC replacements were infrarenal. Morbidity was 10.6%: one each with bowel obstruction, chyle leak, renal failure with complete recovery (left RV reimplant, right nephrectomy), reoperation for bleeding, and IVC graft thrombosis. Morbidity did not differ by type of reconstruction. There was no mortality. Follow-up ranged from 1.5 to 216 months (18 years) with a mean of 3.5 years. Computed tomography or duplex scans were available in 28 of 47 patients and in 15 of 27 patients in group 3 at a mean follow-up of 36 and 20 months, respectively. One IVC graft thrombosis was documented at 10 months after chemotherapy/sepsis. Tumor recurrence caused three graft stenoses. Cumulative 5-year patency in group 3 was 80% (imaging) and 92% (clinical). Lower extremity edema was universally avoided. Cumulative 5-year survival for the series was 45% ± 8.5%. Mean long-term survival was 5.8 ± 0.56 years (range, 4 months-17 years), with a significant difference between primary or patch (mean, 6.5 years) and circumferential or extensive repair (mean, 4.2 years; P < .005). Cumulative (47% vs 52%) and mean (3.1 vs 3.6 years; P > .12) survival was similar between patients with single-segment and extensive IVC resection and replacement. Conclusions: IVC resection and reconstruction for en bloc tumor excision is safe, even when extensive repairs are necessary. Replacement of the IVC with prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival depends on tumor behavior and degree of IVC involvement, where primary and patch repair has a better prognosis than circumferential resection.

Discussion

2012-03-05

Dr Gregory J. Landry (Portland, Ore). The authors present their data on inferior vena cava reconstruction during retroperitoneal tumor resection, an experience of 47 patients over 2 decades. The results are exemplary, with no perioperative mortality and a complication rate of only 10%, most of which were transient. This is remarkable given the extensive nature of these procedures, which typically include several hours of surgery by the surgical oncologists in addition to the extensive vascular reconstruction performed by the consulting vascular surgeon.

Population-based analysis of inpatient vascular procedures and predicting future workload and implications for training

Jeffrey Jim, Pamela L. Owens, Luis A. Sanchez, Brian G. Rubin — 2012-01-16

Objective: The purpose of this study was to analyze the trend in inpatient vascular procedures in the United States over the past decade and predict the future demand for vascular surgeons. Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried to determine the weighted national estimates of inpatient vascular procedures performed on adult patients (age ≥18) between 1997 and 2008. Using population estimates from the United States Census Bureau, the per capita rates of inpatient procedures were calculated for age-specific groups (18-64 years, 65-84 years, and ≥85 years). The change in per capita rates over the past decade along with population forecasts were used to predict future workload. Results: There was a net increase of 22% from 971,046 inpatient vascular procedures for all adults in 1997 to 1,188,332 in 2008. During the same time period, the adult population increased by 16% from 198 to 230 million. The age-stratified per capita rates of all vascular procedures were +21% for age 18 to 64; −4% for age 65 to 84; and +18% for age ≥85. This resulted in a net increase of 5% (490 to 515 procedures per 100,000 capita) in the per capita rate for all adults. Based on the assumption that trends in age-specific rates remain constant, there is a predicted inpatient workload increase (compared to 2008) of 18% by 2015, 34% by 2020, and 72% by 2030. The vascular workload is predicted to more than double by the year 2040. Conclusions: Despite a conservative approach of using a population-based analysis of only inpatient procedures, there is a dramatic increase in the predicted vascular workload for the future. The vascular surgery training process will need to adapt to ensure an adequate number of fellowship-trained vascular surgeons is available to provide quality vascular care in the future.

Discussion

2012-01-16

Dr Julie Ann Freischlag (Baltimore, Md). I had a question about risk factor modification and prevalence of disease, such as we think there is going to be more diabetes and more obesity but the impact of less smoking and perhaps better control of lipids. How do you even try to attempt that in your analysis? Is there a way we can look at that?

Role of aortic stent graft oversizing and barb characteristics on folding

Kathleen K. Lin, Jarin A. Kratzberg, Madhavan L. Raghavan — 2012-02-10

Objective: To evaluate folding in infrarenal stent grafts in relation to oversizing, barb angle, and barb length using computed tomography images of stent grafts deployed in explanted bovine aortas. Methods: Computed tomography data from an in vitro investigation on the effect of oversizing of 4% to 45% (n = 19), barb length of 2 to 7 mm (n = 11), and barb angle of 10° to 90° (n = 7) on device fixation were examined for instances of folding. Folding was classified as circumferential or longitudinal and quantified on an ordinal scale based on codified criteria. Cumulative fold ranking from 0 (no fold) to 6 (two severe folds) for each deployment was used as the measure of folding observed. Results: Of the 37 cases, cumulative mean ± standard deviation fold ranking for stent grafts oversized >30% (n = 5) was significantly greater than the rest (3.4 ± 1.7 vs 0.5 ± 1.2, respectively; Mann-Whitney U test; P < .005). When barb length was varied from 2 to 7 mm (oversizing held at 10%-20%), folding was noted in one of 11 cases. Similarly, when barb angle was varied from 0° (vertical) to 90° (horizontal), folding was not noted in any of the seven cases. The pullout force was not significantly different between stent grafts with and without folding (5.4 ± 1.95 vs 5.12 ± 1.89 N, respectively; P > .5). At least one instance of folding was noted in the seven of seven (100%) stent grafts with oversizing >23.5% and in only five of 30 (14%) stent grafts with oversizing <23.5%. Conclusions: Stent graft folding was prevalent when oversized >30%. Large variations in barb length and angle did not aggravate folding risk when oversized within the recommended range of 10% to 20%. Clinical Relevance: In endovascular repair, a better understanding of the nature of stent graft deployment can improve treatment outcomes and device design. Folding of stent grafts affects graft apposition and, consequently, performance. In this study, the roles played by key stent graft variables on the propensity for folding were assessed in a controlled in vitro setting.

Endovascular creation of aortic dissection in a swine model with technical considerations

2012-01-09

Objective: Creating an experimental model of a type B aortic dissection with a minimally invasive endovascular procedure in swine to help future evaluation of therapies for aortic dissection. Methods: Aortic dissection was created in 14 swine using endovascular procedures only. Under fluoroscopy, a modified 10F outer catheter with a 14 G stiffening inner metallic cannula was forced via the femoral artery into the aortic vessel wall to create an initial dissection. A .035-inch guidewire and a 4F straight catheter were advanced into the dissected space, and the dissection was extended in a retrograde direction using a technique including loop formation of the guidewire, which was placed carefully against the transmural penetration and extended as far as possible in the descending thoracic aorta up to the point where loop formation of the guidewire reached smoothly. An 8F introducer sheath was advanced with a Brockenbrough needle into the dissected space, and a proximal fenestration was created by puncturing the intima. If required, balloon dilatation was performed to enlarge the proximal and distal tears. Aortography and contrast-enhanced cone beam computed tomography (CBCT) were performed in addition to a detailed histologic evaluation of the dissected portion. Results: Aortic dissection was successfully created in 11 of the 14 swine (78.6%). Among the 11 dissections, nine were located in the thoracoabdominal aorta and two in the abdominal aorta. The initial aortic diameter at the middle portion of the created dissection ranged from 7.4 to 16.8 mm (mean ± standard deviation, 10.9 ± 2.9), while after dissection, it ranged from 7.8 to 19.3 mm (12.9 ± 3.8 mm). The dissected length ranged from 4.4 to 17.7 cm (10.7 ± 4.6 cm). Aortography and CBCT revealed seven dissections (63.6%) with a smooth and patent false lumen. Histologic evaluation revealed that the outer one-third of the media was separated from the inner two-thirds. In the remaining four dissections (36.4%), imaging procedures revealed the formation of a rough and patent false lumen beside the true lumen, and histologic evaluation revealed greater separation of the outer media. Five animals were chronic dissection models. Three (60%) of these survived for more than 14 days without any symptoms. Moreover, completely patent true and false lumens without thrombus formation were observed in these three animals. The aortic diameter at the dissected portion tended to be dilated compared with the initial diameter. Conclusions: This new technique of creating an experimental aortic dissection model in swine is promising and should contribute to the development of future therapies for aortic dissection. Clinical Relevance: This study demonstrates the development of a new and attractive experimental model of type B aortic dissection using a minimally invasive endovascular procedure in swine, which should develop new therapies and improve the currently practiced endovascular therapies for type B aortic dissection such as stent graft placement. Previous attempts to surgically create animal models have also had contributions but were hardly applicable due to their invasiveness. Another advantage of this study is that it uses computed tomography as a clinically indispensable tool for the diagnostic evaluation of hemodynamic pathology in the created aortic dissection.

Preliminary findings in quantification of changes in septal motion during follow-up of type B aortic dissections

2012-02-20

Objective: To quantify longitudinal changes in intra-arterial septum (IS) motion with two-dimensional (2D) phase-contrast magnetic resonance imaging (2D pcMRI) in type B aortic dissections (AD) to improve the understanding of AD and its midterm development. Methods: From a database of 42 patients who underwent a dynamic magnetic resonance imaging (MRI) examination at the Acute Aortic Treatment Center of The Methodist DeBakey Heart & Vascular Center, 2D pcMRI image data was available from 10 patients with type B AD for both short-term (mean, 6.6 days; range, 1-10 days; n = 7) and midterm follow-up (mean, 155 days; range, 60-324; n = 5). IS motion was quantified as motion of IS boundary points averaged over the cardiac cycle. Relative change in IS motion was expressed as percent change compared with initial presentation. Maximum IS extension (true lumen [TL] expansion) and contraction (TL compression), IS fraction in phase with aortic flow and correlation of IS motion with aortic flow (IS compliance) were quantified. Results: IS motion at initial presentation was 0.68 ± 0.2 mm and was reduced at short-term (0.48 ± 0.3 mm; P = .07) and midterm (0.5 ± 0.2 mm; P = .1) follow-up. Trend in relative change of IS motion was variable during short-term follow-up: reduced in three subjects (−75% ± 6%) and elevated in four subjects (48% ± 23%). During midterm follow-up, relative change in IS motion was reduced in four subjects (28% ± 19%) and slightly elevated in one (6.2%). IS contraction decreased with follow-up while IS extension slightly increased. Fraction of IS moving in phase with aortic flow increased but IS compliance decreased, suggesting increasing IS stiffness. Conclusions: Reduction of IS motion in AD is seen with short-term and midterm follow-up. Intersubject variability of this trend is high at short-term follow-up but low at midterm follow-up. Detailed analysis of IS motion parameters indicate reduction of IS contraction and IS compliance with time. This has potential implications for endovascular management of type B aortic dissections, as expansion of aortic stent grafts can be limited by a stiff IS. Clinical Relevance: The management algorithm for type B aortic dissections has remained essentially unchanged over the past several decades despite advances in both imaging technology and options for endovascular management of the aorta. In part, this may be due to the underutilization of dynamic imaging modalities with their potential to evaluate the diseased aorta on an individualized basis. Although intra-arterial septum (IS) stiffness has long been accepted as a marker for chronicity of a dissection, changes in IS mobility over time have not yet systematically been investigated. In this study, we have demonstrated that IS motion can be quantified with dynamic magnetic resonance imaging methods (in particular, two-dimensional phase-contrast magnetic resonance imaging). The first results presented here indicate that IS motion may be reduced over time, reaching statistical significance at long-term follow-up. Variable behavior at presentation and midterm also indicate that basing management on our current definitions of acute and chronic based on time since presentation alone may not be reasonable. These patterns could determine which patients are more likely to benefit from interventions and which are likely to have poor outcomes from thoracic endovascular repair.

Increased activation of the hypoxia-inducible factor pathway in varicose veins

Chung S. Lim, Serafim Kiriakidis, Ewa M. Paleolog, Alun H. Davies — 2012-01-27

Background: Venous hypoxia has been postulated to contribute to varicose vein (VV) formation. Direct measurements of vein wall oxygen tension have previously demonstrated that the average minimum oxygen tensions were significantly lower in VVs compared with non-varicose veins (NVVs). Hypoxia-inducible factors (HIFs) are nuclear transcriptional factors that regulate the expression of several genes of oxygen homeostasis. This study aimed to investigate if hypoxia was associated with VVs by assessing the expression of HIF-1α, HIF-2α, HIF target genes, and upstream HIF regulatory enzymes in VVs and NVVs, and their regulation by hypoxia. Methods: VVs and NVVs were surgically retrieved and immediately snap-frozen or used for organ culture preparation. The relative expression of HIF-1α, HIF-2α, HIF target genes, and HIF regulatory enzymes in VVs and NVVs was analyzed with quantitative polymerase chain reaction (Q-PCR) and Western blot. VV and NVV organ ex vivo cultures were exposed to 16 hours of normoxia, hypoxia (oxygen tension 1%), or the hypoxia mimetic dimethyloxallyl glycine (DMOG) 1 mM in normoxia. The vein organ cultures were then analyzed for HIF-1α, HIF-2α, and their target gene expression with Q-PCR and Western blot. Results: HIF-1α and HIF-2α mRNA were significantly upregulated in VVs compared with NVVs (89.8 ± 18.6 vs 10.4 ± 7.2 and 384.9 ± 209.4 vs 8.1 ± 4.2, respectively). HIF target gene mRNA expression was also significantly elevated in VVs compared with NVVs, namely glucose transporter-1 (GLUT-1; 8.7 ± 2.1 vs 1.0 ± 0.3), carbonic anhydrase-9 (CA9; 8.5 ± 2.1 vs 2.8 ± 1.2), vascular endothelial growth factor (VEGF; 7.5 ± 2.1 vs 0.9 ± 0.2), and BCL2/adenovirus E1B 19-kDa protein-interacting protein 3 (BNIP-3; 4.5 ± 0.7 vs 1.4 ± 0.3). The upregulation of HIF-1α, HIF-2α, and HIF target genes in VVs was also reflected at protein level. Of the HIF regulatory enzymes, the expression of prolyl-hydroxylase domain (PHD)-2 and PHD-3 was found to be elevated in VVs compared with NVVs. Exposure of VV and NVV organ cultures to hypoxia or DMOG was associated with increases in HIF-1α and HIF-2α protein and HIF target gene expression compared with normoxia only. Conclusions: The study concluded, we believe for the first time, an increased activation of the HIF pathway, with upregulation of the expression of HIF-1α and HIF-2α transcription factors, and HIF target genes, in VVs compared with NVVs. Exposure of VVs and NVVs to hypoxic conditions was associated with increased expression of HIF-1α and HIF-2α protein and HIF target genes. The data suggest that the HIF pathway may be associated with several pathophysiologic changes in the VV wall, and that hypoxia may be a feature contributing to VV pathogenesis. Clinical Relevance: Varicose veins (VVs) cause debilitating symptoms, including pain, skin changes, and ulceration to patients. Despite the burden, the pathophysiology of VVs remains incompletely understood. Vein wall changes are now thought to be the primary events of VV formation. Understanding the upstream regulation of these changes may help to identify new therapeutic targets for VVs. This study examined hypoxia as a potential factor associated with VV wall changes by assessing the hypoxia-inducible factor (HIF) pathway in VVs. The results demonstrate an increased activation of the HIF pathway in VVs which could be regulated by hypoxia, suggesting it as an attractive therapeutic target for the disease.

Loss of lymphatic vessels and regional lipid accumulation is associated with great saphenous vein incompetence

2012-01-06

Objective: Recent studies suggest that biologic changes in the vein wall associated with varicose veins (VVs) occur not only in valvular tissue but also in nonvalvular regions. We previously used imaging mass spectrometry (IMS) to determine the distribution of lipid molecules in incompetent valve tissue. In this study, we used IMS to analyze incompetent great saphenous veins (GSVs) in patients with varicose vein (VV) to assess the distribution of lipid molecules. Methods: We obtained GSV tissue from 38 VV patients (50 limbs) who underwent GSV stripping. For the control veins (CV), we obtained GSV samples from 10 patients undergoing infrainguinal bypass with reversed GSV grafting for peripheral artery occlusive disease (10 limbs). Conventional and immunofluorescence staining were performed for histopathologic examination. The total lipid content in the homogenized vein tissue was determined. The localization of each lipid molecule in the vein wall was assessed by IMS. Results: The histologic examination showed the VV walls were significantly thicker than the CV walls, and only the VV adventitia was positive for lipid staining. The VV wall had higher concentrations of phospholipids and triglycerides than the CV wall. IMS revealed an abnormal accumulation of lysophosphatidylcholine (LPC; 1-acyl 16:0) and phosphatidylcholine (diacyl 16:0/20:4) in the VV intima and media. Triglyceride was found only in VV adventitia. The number of lymphatic vessels, as measured by staining with D2-40, a lymphatic vessel-specific marker, was significantly lower in the VV adventitia than in the CV adventitia. Lymphatic vessel reduction may be associated with insufficient lymphatic drainage in the VV adventitia causing histologic changes in VV tissue. Conclusions: The accumulation of LPC (1-acyl 16:0) and PC (diacyl 16:0/20:4) in the VV intima and media may be associated with chronic inflammation, leading to VV tissue degeneration. Furthermore, insufficient lipid drainage by lymphatic vessel may be responsible for accumulation of lipid molecules and subsequent vein wall degeneration. Clinical Relevance: Abnormal distribution of lipid molecules in varicose vein (VV) tissue in patients at CEAP class C2-3 and C4-5 suggests that VV-associated accumulation of lipid molecules begins in the early clinical stages of the disease and continues through the advanced stages. In particular, the accumulation of both lysophosphatidylcholine (1-acyl 16:0) and phosphatidylcholine (diacyl 16:0/20:4) in the media was significantly higher in VV tissue from patients in advanced clinical stages, suggesting an association between lipid accumulation and chronic inflammation of skin and subcutaneous tissues. Further study is needed to clarify the effect of lymph stasis on VVs and chronic inflammation. The mechanism whereby adventitial lymphatic vessels are damaged is also unknown. Consistent venous hypertension and subsequent overload to the lymphatics may account for the lymphatic damage. In addition, accumulation of possible proinflammatory lipid molecules in VV walls may further damage the adventitial lymphatic vessels.

Early thrombus removal strategies for acute deep venous thrombosis: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum

2012-04-02

Background: The anticoagulant treatment of acute deep venous thrombosis (DVT) has been historically directed toward the prevention of recurrent venous thromboembolism. However, such treatment imperfectly protects against late manifestations of the postthrombotic syndrome. By restoring venous patency and preserving valvular function, early thrombus removal strategies can potentially decrease postthrombotic morbidity. Objective: A committee of experts in venous disease was charged by the Society for Vascular Surgery and the American Venous Forum to develop evidence-based practice guidelines for early thrombus removal strategies, including catheter-directed pharmacologic thrombolysis, pharmacomechanical thrombolysis, and surgical thrombectomy. Methods: Evidence-based recommendations are based on a systematic review and meta-analysis of the relevant literature, supplemented when necessary by less rigorous data. Recommendations are made according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, incorporating the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of the evidence (A to C). Results: On the basis of the best evidence currently available, we recommend against routine use of the term “proximal venous thrombosis” in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade 1A). We further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a first episode of iliofemoral DVT of <14 days in duration (Grade 2C) and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade 1A). We suggest pharmacomechanical strategies over catheter-directed pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic therapy is contraindicated (Grade 2C). Conclusions: Most data regarding early thrombus removal strategies are of low quality but do suggest patient-important benefits with respect to reducing postthrombotic morbidity. We anticipate revision of these guidelines as additional evidence becomes available.

Treatment of acute iliofemoral deep vein thrombosis

2012-03-23

Objective: The objective of this systematic review and meta-analysis was to compare the efficacy of three available treatments for acute iliofemoral deep vein thrombosis (DVT): systemic anticoagulation, surgical thrombectomy, and catheter-directed thrombolysis. Methods: We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and Scopus) and sought additional references from experts. Eligible studies enrolled participants with acute iliofemoral DVT and measured the outcomes of interest. Reviewers working independently in duplicate extracted study characteristics, quality, and outcome data (death, pulmonary embolism, local complications, hemorrhagic complications, postthrombotic syndrome, pain, quality of life, and surrogate markers of venous function such as valve competence and patency). We pooled relative risks (RRs) from each study using the random effects model and estimated the 95% confidence intervals (CIs). Bayesian indirect comparison techniques were used to compare thrombectomy to catheter-directed thrombolysis. Results: We found 15 unique studies that fulfilled eligibility criteria. When compared to systemic anticoagulation, thrombectomy was associated with a statistically significant reduction in the risk of developing postthrombotic syndrome (RR, 0.67; 95% CI, 0.52-0.87), venous reflux (RR, 0.68; 95% CI, 0.46-0.99), and a trend for reduction in the risk of venous obstruction (RR, 0.84; 95% CI, 0.60-1.19). When compared to systemic anticoagulation, pharmacologic catheter-directed thrombolysis was associated with statistically significant reduction in the risk of postthrombotic syndrome (RR, 0.19; 95% CI, 0.07-0.48), venous obstruction (RR, 0.38; 95% CI, 0.18-0.37), and a trend for reduction in the risk of venous reflux (RR, 0.39; 95% CI, 0.16-1.00). Overall, the quality of evidence was low; downgraded due to the observational nature of the majority of studies, lack of comparability of study cohorts at baseline, loss to follow-up, imprecision, and indirectness of outcomes (surrogacy). There were insufficient data to compare the outcomes of thrombectomy to catheter-directed thrombolysis. Conclusions: Low-quality evidence suggests that surgical thrombectomy decreases the incidence of postthrombotic syndrome and venous reflux. Catheter-directed pharmacologic thrombolysis decreases the incidence of postthrombotic syndrome and venous obstruction.

Endovascular repair of a traumatic arteriovenous fistula involving the iliac bifurcation using an iliac branch device

2012-01-27

Endovascular techniques have shown to be useful in the management of vascular injuries because they transform a complex and potentially dangerous procedure into a safe one. We present the case of a 39-year-old man with congestive heart failure and abdominal bruit 11 years after an abdominal gunshot wound. Imaging studies revealed an arteriovenous fistula involving the left iliac artery bifurcation, and an iliac branch device was used to treat it. Symptoms resolved, and follow-up imaging showed patency of the graft and closure of the arteriovenous communication. To our knowledge, this is the first report of a nonaneurysmal disease treated with this device.

Endovascular solutions to arterial injury due to posterior spine surgery

2011-01-10

Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. We identified five patients with iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe their endovascular treatment. Intraoperative arterial bleeding was encountered in two patients during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patient was placed supine. In both patients, angiography demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting/penetrating the thoracic or abdominal aorta. Angiography or intravascular ultrasound imaging, or both, confirmed indention/perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. Endovascular repair of arterial injuries occurring during posterior spinal procedures is feasible and can offer a safe and less invasive alternative to open repair.

Left renocaval venous bypass with autologous great saphenous vein for nutcracker syndrome

Yang Liu, Yan Sun, Xing Jin — 2011-11-03

Nutcracker syndrome results from left renal vein compression by the abdominal aorta and the superior mesenteric artery. The consecutively increased renal venous pressure results in hematuria, proteinuria, flank pain, left-sided varicocele, pelvic congestion, and others. We report a 25-year-old man with nutcracker syndrome who underwent successful left renocaval venous bypass with autologous great saphenous vein. The patient's condition clearly improved, with no clinical relapse after treatment. Ultrasound imaging showed patency of the venous bypass and decreased venous hypertension. This technique is a feasible choice for surgical treatment of nutcracker syndrome, with a low incidence of complications and satisfactory results.

Leiomyosarcoma of the splenic vein

Mark J. Gage, Elliot Newman, Thomas S. Maldonado, Cristina H. Hajdu — 2011-11-03

Leiomyosarcomas are smooth muscle-derived tumors generally found intra-abdominally in the retoperitoneum, mesentery, or omentum. Only approximately 5% of these tumors originate from vessel wall smooth muscle. Those derived from the splenic vein are exceedingly rare, with only one previously published case in the literature. We present a second case of leiomyosarcoma of the splenic vein in a 58-year-old woman with 2 months of epigastric pain. A distal pancreatectomy was performed to include the tumor found centered in the splenic vein at the splenic and portal vein confluence and growing into the pancreas in the body on the posterior aspect. A saphenous vein patch was used for reconstruction.

Superior vena cava occlusion caused by Behçet disease

Miao Yu, Anbing Shi, Bi Jin, Xionggang Jiang, Huimin Liang, Chenxi Ouyang — 2011-12-12

This case report described a patient of Behçet disease (BD)-related vascular lesions that initially presented as occlusion of superior vena cava (SVC) without any evidence of thrombosis. The patient was treated first by percutaneous transluminal angioplasty and stent implantation, and he developed thrombosis in the stent and then received open bypass operation. Pathologic examination of the SVC specimen and the postoperative manifestations revealed that the underlying cause of his symptoms as BD. Afterward, methylprednisolone plus anticoagulant therapy was routinely given, which relieved the symptoms of the patient.

Arteriovenous fistula after endovenous ablation for varicose veins

2011-11-28

Endovenous ablation, using radiofrequency or laser, is becoming the mainstay of treatment for symptomatic varicose veins in the setting of saphenous vein incompetency. Both procedures have been shown to produce high rates of truncal vein occlusion with few complications. This article presents three patients who developed arteriovenous fistula (AVF) following great saphenous vein treatment: two following radiofrequency ablation (RFA) and one following laser ablation. This is the first published report of AVF following RFA for which operative details are known. We review the literature and discuss possible causes and management of this rare complication.

Thoracic outlet syndrome caused by pseudoarticulation of a cervical rib with the scalene tubercle of the first rib

Anita Balakrishnan, Philip Coates, Christopher A. Parry — 2012-05-01

A healthy 20-year-old man presented with a bony lump above the left clavicle associated with upper limb pain, numbness, and tingling. Examination in the surrender position elicited left hand weakness and pain with loss of the radial pulse. The patient had paresthesia of the ulnar border of the left hand but no interossei wasting.

Preaortic left primitive iliac vein

Silvia Cabrera, Berta Díaz-Feijoo, Jordi Xercavins, Antonio Gil-Moreno — 2012-05-01

A 28-year-old woman was admitted for staging surgery of an ovarian carcinoma. The patient had been diagnosed with a clear-cell ovarian carcinoma associated with a giant endometrioid cyst 3 weeks before. The computed tomography scan did not describe tumoral implants or lymphadenopathies, or any vascular malformation. A laparoscopic adnexectomy was performed in the first surgery. The pathologic study showed a clear-cell carcinoma, histologic grade 3.

The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies

2012-01-12

Objective: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The “chimney graft” or “snorkel” technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. Methods: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. Results: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. Conclusions: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data.

Comparison of the five 2011 guidelines for the treatment of carotid stenosis

Kosmas I. Paraskevas, Dimitri P. Mikhailidis, Frank J. Veith — 2012-05-01

In 2011, five independent, international guideline committees reported their recommendations for the management of symptomatic and asymptomatic carotid artery stenosis. These included the American College of Cardiology/American Heart Association, the Society for Vascular Surgery, the European Society of Cardiology, the Australasian, and the UK National Institute of Health and Clinical Excellence. As the recommendations of these five guideline committees were based on the same published literature, it would be expected that they are similar, at least to a large extent. Surprisingly, there were considerable differences between the five guidelines regarding the management of both symptomatic and asymptomatic carotid patients. The differences in the recommendations between the five Guideline Committees are analyzed and discussed.

Invited commentary

Richard P. Cambria — 2012-05-01

The debate about the appropriate management of carotid bifurcation disease not only continues but has intensified related to a number of events over the past 18 months. These include (1) publication of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) trial results, including the important follow-up studies emphasizing the clear-cut differences in symptomatic vs asymptomatic patients with regard to periprocedural complications of stroke and death; (2) publication of multiple guideline documents during the calendar year 2011, as reviewed by the authors; (3) increasing emphasis in some quarters to the claim that best/modern medical therapy is sufficient treatment (ie, without any intervention) in asymptomatic patients; and, (4) further considerations by the Centers for Medicare & Medicaid Services (CMS) in the form of a CMS Medical Evidence Development and Coverage Analysis Committee (MEDCAC) meeting that was held January 25, 2012. The MEDCAC panel heard testimony on multiple viewpoints from a variety of stakeholders involved in the management of carotid disease. The Society of Vascular Surgery (SVS) was very involved at a high level in the CMS MEDCAC and provided its views regarding this issue.

Factors affecting career choice among the next generation of academic vascular surgeons

2012-03-23

Objective: Few studies have examined factors that influence an individual's decision to enter an academic medical career after residency training. We sought to evaluate whether sex, ethnicity, child care issues, and debt burden influenced residents' choice for a career in academic vascular surgery. Methods: A 39-item Web survey, designed to elucidate which factors motivated residents to seek a career in academic vascular surgery, was sent to 295 vascular surgery residents currently enrolled in Accreditation Council on Graduate Medical Education-accredited training programs. Results: A total of 128 responses (43%) were received. Of these, 53% of respondents were white and 47% were nonwhite and 34 (27%) were women and 94 (73%) were men. Fifty-seven percent of minorities anticipate a career in academic vascular surgery. There were no statistical differences between sex and ethnicity for factors influencing career choice, including training paradigm, presence of a life partner or dependents, mentorship role, participation in research, service, and teaching, anticipated salary, and debt burden (P > .05). Seventy-seven percent of respondents carry significant debt; of those with debt, 81% owe >$100,000 and 40% owe >$200,000. Seventy-three percent of 0+5 trainees anticipated choosing an academic practice compared with 42% of 5+2 trainees (P < .01). Respondents planning an academic career cited procedural variation, breadth and depth of practice/tertiary referral experience, and research opportunities as the most important drivers of career choice. Income potential, strength of the job market, and child care needs were deemed less important. Conclusions: This study shows that academic vascular surgery is a popular career option for current vascular surgery trainees, especially those in 0+5 programs. Choosing a career in academic vascular surgery appears not to be influenced by sex, ethnicity, child care concerns, salary expectations, or debt burden, even though most trainees carry enormous debt. The data imply future academic vascular surgeons will likely have greater gender and ethnic variability than is currently seen.

Discussion

2012-03-23

Dr Niten Singh (Tacoma, Wash). Dr Danczyk and colleagues have continued the outstanding tradition at OHSU in evaluating vascular surgery education and training techniques. Their study is designed to identify factors involved in future career choices among current vascular residents. Their respondents included residents in traditional (5 + 2) programs as well as those in the integrated (0 + 5) and early specialization (4 + 2) program. The majority of respondents were in a traditional training program (61%), in postgraduate year 7 (29%), and white (53.1%). Surprisingly, the majority of respondents (56%) planned on pursuing academic careers, which is not what has been historically true. Sixty-five percent of women and 57% of ethnic minority respondents planned on entering academic practice as well. There was, however, no statistically significant correlation between gender and ethnicity and their future practice setting.

Impact of endovascular simulator training on vascular surgery as a career choice in medical students

2012-04-01

Objective: The primary goal of this study was to determine whether exposure to endovascular simulator training increases interest in vascular surgery among medical students. Secondary goals were to determine whether interest in vascular surgery is inversely related to the time after exposure, to identify factors associated with interest, and to identify students' characteristics that positively influence performance metrics. Methods: This was a prospective, randomized, crossover study comprising 80 medical students who were randomized into group A (n = 40) and group B (n = 40). Participants completed a survey of their interest in vascular surgery and attitudinal factors using Vascular Surgery Interest Form (VSIF) before exposure to the simulator (pretest). At 1 month after exposure of group A to the simulator, both groups were tested using VSIF (test). Upon completion of testing, group B was exposed to simulator training, whereas group A received no further training. At 2 months after exposure of group B to the simulator, both groups were posttested using VSIF, which asked the students' level of interest in vascular surgery using a 1 to 10 scale. Performance metrics were recorded during each exposure. Differences among cohort demographics were determined using Pearson χ2 analysis. Differences in interest were determined with paired sample correlations. Linear regression and analysis of variance were used to correlate VSIF responses with interest and the performance metrics. Results: Both student cohorts had significant increases in interest after exposure to simulation. In group A, test interest (mean ± standard deviation) was significantly higher than pretest and posttest interests (5.51 ± 1.73 vs 4.00 ± 1.88 vs 4.18 ± 1.82; P < .05). In group B, posttest interest was significantly higher than pretest and test interests (5.62 ± 2.03 vs 3.96 ± 1.61 vs 4.08 ± 1.64; P < .05). The increase in interest was reciprocally related to the time passed since the initial exposure. Resident and attending lifestyle, length of training, radiation concerns, gender identification of a mentor, and personality fit with occupation were not correlated with interest. Sex, medical school year, comfort with endovascular procedures, willingness to work long hours, interest in performing percutaneous procedures, and commitment to surgical career did not affect impact performance metrics. Conclusions: One exposure of students to endovascular simulator training is associated with an increase in vascular surgery interest. Acquired interest is reciprocally related to the time demonstrating the temporal importance of the exposure.

The femoral-based endowedge technique to increase juxtarenal seal and correct graft tilt

David J. Minion, Eleftherios S. Xenos — 2011-12-12

The endowedge technique refers to the use of balloons to align the scallops of the Gore Excluder endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz) to the renal artery to increase juxtarenal seal during endovascular repair of aneurysms with challenging anatomy. With the availability of a reconstrainable deployment system, this now can be performed without the use of brachial access. In addition, the femoral approach facilitates the use of the balloon as a fulcrum to correct unfavorable graft tilt.

Femoral-femoral stabilizing buddy wire for embolization of the internal iliac artery

Connie Zastrow, Raghu L. Motaganahalli, Jon S. Matsumura — 2012-01-03

Internal iliac artery (IIA) embolization is performed in a variety of clinical scenarios, most commonly in patients undergoing endovascular aneurysm repair (EVAR) with an iliac artery aneurysm or inadequate distal landing zone. In these patients, IIA embolization with iliac limb extension is often performed. While IIA embolization can be routinely performed with either ipsilateral or contralateral femoral arterial access, it can be challenging in some patients with an acutely angulated aortic or iliac bifurcation and in patients with short or ectatic common iliac arteries. In this select group of patients with difficult anatomy, IIA embolization can be challenging and may lead to increased radiation exposure and contrast administration. Having a sheath precisely positioned and stabilized at the internal iliac artery origin will facilitate embolization of the IIA. This report describes a novel technique in which crossover femoral-femoral artery buddy wire placement achieves stable positioning of large sheaths for concurrent IIA embolization at the time of EVAR.

The Society for Vascular Surgery Vascular Quality Initiative

Jack L. Cronenwett, Larry W. Kraiss, Richard P. Cambria — 2012-05-01

The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) is designed to improve the quality, safety, effectiveness, and cost of vascular health care. It uses the structure of a Patient Safety Organization to permit collection of patient-identified information but protect benchmarked comparisons from legal discovery. The SVS VQI is uniquely organized as a distributed network of regional quality groups to facilitate local translation of registry data into practice change while maintaining the power of a national registry. Detailed data specific to each commonly performed open and endovascular procedure are collected, both in-hospital and at ≥1 year of follow-up. Quality measures are reported to physicians and hospitals, which allow anonymous risk-adjusted benchmarking within regions or nationally. All specialties that perform vascular procedures are included, and international participation is encouraged. This review describes the current status of the SVS VQI.

Adjunctive use of the superficial femoral vein for vascular reconstructions

Sean P. Roddy — 2012-05-01

The add-on CPT code 35572 denotes “Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure)” in the 2012 edition of the CPT manual. This specifically refers to procurement of deep vein in the thigh for the purpose of either arterial or venous revascularization. The removed venous segment may be anything from a piece excised with a side biting clamp for arterial patch closure all the way to harvest of the entire femoral vein from the popliteal region to its confluence with the deep femoral vein for bypass. The final reconstruction can involve vein patch angioplasty for occlusive disease, aneurysmorrhaphy with venous patch/bypass, or simply operative bypass using this segment for conduit.

Age and Outcomes After Carotid Stenting and Endarterectomy: The Carotid Revascularization Endarterectomy Versus Stenting Trial

J.H. Voeks, G. Howard, G.S. Roubin, CREST Investigators — 2012-05-01

Outcomes after carotid artery stenting (CAS) vs carotid endarterectomy (CEA) are related to patient age, with increased risk of stroke with increasing age in patients undergoing CAS.

Combined Proximal Endografting With Distal Bare-Metal Stenting for Management of Aortic Dissection

S.C. Hofferberth, P.T. Foley, A.E. Newcomb — 2012-05-01

Staged total aortic and branch vessel endovascular reconstruction is a feasible endovascular technique to address the problems of distal true lumen collapse, incomplete aortic remodeling, and late aneurysm formation in patients with aortic dissection.

Doppler Criteria for Identifying Proximal Vertebral Artery Stenosis of 50% or More

M. Yurdaku, M. Tola — 2012-05-01

A peak systolic velocity (PSV) ratio is the best Doppler parameter for identifying proximal vertebral artery stenosis. About 20% of patients with posterior circulation ischemia have occlusive disease in the proximal vertebral artery (Caplan LR et al, Ann Neurol 2004;56:389-98). The V1 segment of the vertebral artery is that portion of the artery extending from its origin to entry into the transverse foramen of C6 and is a common site for atherosclerotic disease of the vertebral artery. Most carotid artery duplex scans include insonation of the vertebral artery, but very few studies have been performed to determine Doppler criteria for proximal vertebral artery stenosis. In this study through comparisons of duplex scanning with digital subtraction angiography, the authors sought to determine criteria for identification of proximal >50% vertebral artery stenosis. There were 48 patients with vertebral artery stenosis examined prospectively with color duplex scanning and digital subtraction angiography. Receiver operating characteristic curve analysis was used to determine PSV, PSV ratio, end-diastolic velocity (EDV), and EDV ratio criteria for detecting a >50% proximal vertebral artery stenosis. The parameter with the highest accuracy for the detection of ≥50% proximal vertebral artery stenosis was the PSV ratio (area under the receiver operating characteristic curve, 0.967; 95% confidence interval, 0.899-0.994). A PSV ratio of >2.2 was the optimal criteria for identifying >50% proximal vertebral artery stenosis with a sensitivity of 96% and specificity of 89%. Optimal thresholds for other Doppler parameters to identify >50% proximal vertebral artery stenosis were PVS >108 cm/s, EDV >36 cm/s, and EDV ratio >1.7.

Emergent Endovascular Recanalization for Cervical Internal Carotid Artery Occlusion in Patients with Presenting With Acute Stroke

E.F. Hauck, S.K. Natarajan, H. Ohta — 2012-05-01

Endovascular carotid recanalization should be encouraged for acute cervical internal carotid artery occlusion in younger patients with partial distal preservation of the internal carotid artery (ICA).

Health-Related Quality of Life After Carotid Stenting Versus Carotid Endarterectomy: Results from CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial)

D.J. Cohen, J.M. Stolker, K. Wang, CREST Investigators — 2012-05-01

Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are associated with similar overall health-related quality of life (HRQOL) at 1 year. Stroke has a greater and more consistent sustained impact on HRQOL than myocardial infarction (MI).

Importance of Specimen Length During Temporal Artery Biopsy

E. Ypsilantis, E.D. Courtney, N. Chopra — 2012-05-01

Erythrocyte sedimentation rate (ESR) and length of temporal artery biopsy (TAB) specimen are independent prognostic factors for a positive TAB result. Giant cell arteritis (GCA) affects medium sized and large arteries, most commonly the extracranial arteries of the head and neck. GCA has an incidence of 15 to 25 ×105 per year in patients aged >50 years and is more common in woman (Bengtsston BA, Arthritis Rheum 1981;24:899-904). Because of the potential complication of blindness, treatment with steroids is often urgently instituted when the diagnosis is suspected. Duplex ultrasound imaging is an accurate, noninvasive, first-line investigation for GCA. However, treatment is generally based on a TAB specimen, and TAB is recommended for investigation of GCA (Dasgupta B et al, Rheumatology 2010;49:1594-7). The likelihood of a positive TAB may be related to obtaining an adequate length of temporal artery for analysis, but the minimum length is debatable. The purpose of this retrospective study was to explore potential associations between TAB specimen length and diagnostic sensitivity. The authors examined histopathologic reports and medical records of patients who underwent TAB in six hospitals between 2004 and 2009. There were 966 biopsy specimens analyzed. Median postfixation specimen length was 1 cm (range, 0.1-8.5 cm). There were 207 (21.4%) that were positive for GCA. Among hospitals, there were variations in prebiopsy ESR, arterial specimen length, and positive results. By multivariable analysis, ESR value, patient age, and specimen length were independent predictors of GCA. There were longer median specimen lengths in patients with positive TAB results vs those with negative results, 1.2 cm (range 0.3-8.5cm) vs. 1.0 cm (range, 0.2-8.0 cm), respectively (P = .001). Specimen length by receiver operating characteristic (ROC) curve analysis of at least 0.7 cm was the cutoff length providing the highest positive predictive value for a positive TAB (area under ROC curve, 0.574). There was a significantly higher rate of positive results when the biopsy specimen length was ≥0.7 cm vs specimens with a shorter length (24.8% vs 12.9%; odds ratio; 2.17; P = .001).

Long-term Follow-up of Acute type B Aortic Dissection: Ulcer-like Projections in Thrombosed False Lumen Play a Role in Late Aortic Events

S. Miyahara, N. Mukohara, M. Fukuzumi — 2012-05-01

In patients with acute type B aortic dissection, thrombosed false lumens with ulcer-like projections (ULPs) and patent false lumens have adverse influences on the rate of late aortic dilation and late aortic events.

Long-term Outcome After Additional Catheter-Directed Thrombolysis Versus Standard Treatment for Acute Iliofemoral Deep Vein Thrombosis (the CaVen T Study): A Randomised Controlled Trial

T. Enden, Y. Haig, N-.E. Klow — 2012-05-01

Catheter-directed thrombolysis (CDT) should be considered in patients with proximal deep vein thrombosis (DVT) and a low risk of bleeding. Patients with symptomatic DVT of the popliteal and more proximal veins have up to a 50% incidence of some degree of post-thrombotic syndrome (PTS; Prandoni P et al. Ann Intern Med 2004;141:249-56). A recent systematic review suggested thrombus removal lowers the incidence of PTS (Watson LI et al. Cochrane Database Syst Rev 2004;4:CD002783). The Catheter-Directed Venous Thrombolysis Study evaluated if the addition of CDT to standard anticoagulation for iliofemoral venous thrombosis improved the long-term prevalence of PTS after iliofemoral DVT. This was an open-label, randomized, controlled trial. Patients (aged 18-75 years) were recruited from 20 hospitals in southeastern Norway. To be included, the DVT had to be a first-time iliofemoral DVT and patients had to be entered into the study ≤21 days of symptom onset. Patients were randomly assigned to conventional treatment alone or CDT with alteplase. Randomization was stratified for involvement of pelvic veins. The two primary outcomes were frequency of PTS, as assessed by the Villalta score at 24 months, and iliofemoral venous patency at 6 months. An intention-to-treat analysis was used. There were 209 patients randomly assigned to the treatment groups (108 to control and 101 to CDT). At 24 months, follow-up data for clinical status was available in 189 patients (95%: 99 controls, 90 CDTs), and 37 patients (41.1%, 95% confidence interval [CI] 31.5%-51.4%) allocated to additional CDT presented with PTS compared with 55 (55.6%, 95% CI, 45.7%-65.0%) in the control group (P = .047). The difference in PTS corresponds to an absolute risk reduction of 14.4% (95% CI, 0.2%-27.9%), and the number needed to treat was seven (95% CI, 4-502). At 6 months, iliofemoral patency was reported in 58 patients (65.9%, 95% CI, 55.5%-75.0%) in the CDT group vs 45 (47.4%, 95% CI, 37.6%-57.3%) in the control group (P = .012). There were 20 bleeding complications related to CDT, including three major and five clinically relevant bleeding events.

Outcome After 7 Years of Carotid Artery Stenting and Endarterectomy in Sweden – Single Centre and National Results

D. Lindström, M. Jonsson, J. Formgren, M. Delle, S. Rosfors, P. Gillgren — 2012-05-01

Objectives: The aim was internal vascular centre quality-control measures to compare single-centre results with the national perspective, as well as Analysing the Swedish results from carotid artery stenting (CAS) and comparing a relatively high-volume single centre with the Swedish Vascular Registry (Swedvasc) data. The second aim was to compare CAS and carotid artery endarterectomy (CEA) outcomes for the same 7-year period.

Endovascular Repair of Abdominal Aortic Aneurysm does not Improve Early Survival versus Open Repair in Patients Younger than 60 Years

2012-05-01

Objectives: Multiple randomised trials have demonstrated lower perioperative mortality after endovascular aneurysm repair (EVAR) compared to open surgical repair for infrarenal abdominal aortic aneurysms (AAAs). However, in these trials the mortality advantage for EVAR is being lost within 2 years of repair and the patients evaluated are relatively older with no study specifically comparing EVAR and open repair for patients younger than 60 years of age.

Measuring the Maximum Diameter of Native Abdominal Aortic Aneurysms: Review and Critical Analysis

A. Long, L. Rouet, J.S. Lindholt, E. Allaire — 2012-05-01

Objectives: Maximum diameter is a determinant parameter for the clinical management of asymptomatic abdominal aortic aneurysm (AAA). However, its measurement is not standardised. We review the different methods used to measure AAA maximum diameter, with ultrasound (US) or computed tomography (CT).

Treatment of Aortic Arch Aneurysms with a Modular Transfemoral Multibranched Stent Graft: Initial Experience

2012-05-01

Objectives: To present initial experience with a new modular transfemoral multibranched stent graft for treating aortic arch aneurysms. Methods: Six patients, considered high risk for open surgery, were treated with custom made branched stent grafts. All patients had a staged left carotid subclavian bypass before the endovascular procedure. Each branched graft had a 12 mm side branch for the innominate artery and an 8mm side branch for the left common carotid artery.

Measurement and Optimization of Patient Radiation Doses in Endovascular Aneurysm Repair

2012-05-01

The study assessed radiation exposure during EVAR. Two types of patient dose were estimated: effective dose (ED), which allows estimation of radiation risk to the EVAR patient population; and Peak Skin Dose (PSD), which allows us assess the potential for an individual patient to receive a radiation skin injury. An ancillary aim was to examine dose optimization in EVAR procedures.

Predictors of Early Graft Failure After Infrainguinal Bypass Surgery: A Risk-adjusted Analysis from the NSQIP

R.T. Lancaster, M.F. Conrad, V.I. Patel, R.P. Cambria, G.M. LaMuraglia — 2012-05-01

Introduction and objectives: Infrainguinal bypass surgery (BPG) is accompanied by significant 30-day mortality and morbidity, including early graft failure. The goal of this study is to identify patient- and procedure-specific factors which predict the rate of early graft failure in contemporary practice.

Cost and Effectiveness of Laser with Phlebectomies Compared with Foam Sclerotherapy in Superficial Venous Insufficiency. Early Results of a Randomised Controlled Trial

C.R. Lattimer, M. Azzam, E. Kalodiki, E. Shawish, P. Trueman, G. Geroulakos — 2012-05-01

Objectives: Quantify endovenous laser ablation (EVLA) with concurrent phlebectomies and ultrasound-guided foam sclerotherapy (UGFS) in cost and effectiveness at 3 weeks and 3 months.

Regarding “Trends in the national outcomes and costs for claudication and limb threatening ischemia: Angioplasty vs bypass graft”

Antonio V. Sterpetti — 2012-05-01

I read with much interest the article “Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty versus bypass graft” by Sachs et al, which appeared in the October issue of the Journal. The authors analyzed the results and costs of angioplasty with or without stenting and bypass surgery, reviewing the data of the National Registry.

Regarding “A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease”

Joost Anton Bekken, Bram Fioole — 2012-05-01

We have read the recent article “A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease” by Mwipatay et al. We would like to congratulate the authors on their study, which is the first randomized controlled trial to show that polytetrafluoroethylene (PTFE)-covered stents indeed provide a higher freedom from restenosis rates compared to bare metal stents. We do, however, believe that there are some important limitations to the study, which reduce its applicability for daily practice.

Reply

Bibombe Patrice Mwipatayi, Shannon Thomas, Vikram Vijayan — 2012-05-01

Thank you for your questions regarding our trial in particular regarding the anatomical characteristics of the common and external iliac segments. We agree that the two iliac segments have distinct anatomical and pathophysiologic properties and, hence, will behave differently when stented with either a covered or bare-metal stent. In our study, we concentrated on the aortoiliac segment, as defined as the distal aorta and common iliac arteries. The common iliac artery was the only vessel to have a covered stent deployed within it. Fourteen patients had their external iliac arteries stented, and this was with a more flexible bare-metal stent in all patients. The improved patency is related to restenosis of the covered aortoiliac segments and not to the more distal stented lesions. We apologize if this was not made clearer in the article.

Correction

2012-05-01

In the March 2012 issue of the Journal of Vascular Surgery, the article by Dr Donas et al (Donas KP, Pecoraro F, Torsello G, Lachat M, Austermann M, Mayer D, et al. Use of covered chimney stents for pararenal aortic pathologies is safe and feasible with excellent patency and low incidence of endoleaks. J Vasc Surg 2012;55:659-65) listed an error in . The endoleak type I row should have listed the total number of patients in the self-expanding covered stent group as 35. The corrected table is as follows:

Correction

2012-05-01

In the March 2012 issue of the Journal of Vascular Surgery, the article by Dr Comerota et al (Comerota AJ, Grewal N, Martinez JT, Chen JT, DiSalle R, Andrews L, et al. Postthrombotic morbidity correlates with residual thrombus following catheter-directed thrombolysis for iliofemoral deep vein thrombosis. J Vasc Surg 2012;55:768-73) listed an error in . The Villalta scores for group 1 and group 2 were reversed. The corrected table is as follows:

Editorial Board

2012-05-01

Information for authors

Anton N. Sidawy, Bruce A. Perler — 2012-05-01

Complete information for authors and editorial policies are available in the January and July issues, at our Web site www.jvascsurg.org, or at our Editorial Manager Web site at jvs.editorialmanager.com. An abbreviated checklist for manuscript submission follows. Manuscripts that are accepted for publication become the property of the Journal of Vascular Surgery®, which is copyrighted by the Society for Vascular Surgery®. They may not be published or reproduced in whole or in part without the written permission of the author(s) and the Journal.

Information for readers

2012-05-01

Communications regarding original articles and editorial management should be addressed to Anton N. Sidawy, MD, and Bruce A. Perler, MD, Editors, Journal of Vascular Surgery, 633 N. St. Clair, 22nd Floor, Chicago, IL 60611; telephone: 312-334-2317; fax: 312-334-2320; e-mail: JVASCSURG@vascularsociety.org. Information for authors appears in the January and July issues, at www.jvascsurg.org, and at jvs.editorialmanager.com. Authors should consult this document before submitting manuscripts to this Journal. Address business communications to Journal Publisher, Elsevier Inc, 360 Park Avenue South, New York, NY 10010-1710. For Events of Interest, contact Andrew O'Brien, Journal Manager, at a.obrien@elsevier.com. Visit our Web site at www.jvascsurg.org

Events of interest

2012-05-01

News items of interest to the vascular surgeon must be received at least 8 weeks before the desired month of publication. Announcements published at no charge include those received from a sponsoring society of this Journal, those courses and conferences sponsored by state, regional, national, or international vascular surgical organizations, and university-sponsored continuing medical education courses. All other news items selected for publication carry a charge of $60.00 US for each insertion, and the fee must accompany the request to publish. Send announcements and payment, payable to this Journal, to Issue Management, Elsevier Inc., 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA, 19103.