Journal of Vascular Surgery

Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals

2010-07-14

Background: Abdominal aortic aneurysm (AAA) disease is an insidious condition with an 85% chance of death after rupture. Ultrasound screening can reduce mortality, but its use is advocated only for a limited subset of the population at risk.Methods: We used data from a retrospective cohort of 3.1 million patients who completed a medical and lifestyle questionnaire and were evaluated by ultrasound imaging for the presence of AAA by Life Line Screening in 2003 to 2008. Risk factors associated with AAA were identified using multivariable logistic regression analysis.Results: We observed a positive association with increasing years of smoking and cigarettes smoked and a negative association with smoking cessation. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. Blacks, Hispanics, and Asians had lower risk of AAA than whites and Native Americans. Well-known risk factors were reaffirmed, including male gender, age, family history, and cardiovascular disease. A predictive scoring system was created that identifies aneurysms more efficiently than current criteria and includes women, nonsmokers, and individuals aged <65 years. Using this model on national statistics of risk factors prevalence, we estimated 1.1 million AAAs in the United States, of which 569,000 are among women, nonsmokers, and individuals aged <65 years.Conclusions: Smoking cessation and a healthy lifestyle are associated with lower risk of AAA. We estimated that about half of the patients with AAA disease are not eligible for screening under current guidelines. We have created a high-yield screening algorithm that expands the target population for screening by including at-risk individuals not identified with existing screening criteria.

Invited commentary

Michael P. Lilly — 2010-09-01

This is an important article. These results will expand our knowledge, inform future study, and drive government policy. Critics will point out that the data set is flawed and that the application of the scoring system to the National Health and Nutrition Examination Survey (NHANES) data is speculative. They are correct on both counts, but these criticisms do not negate the value of this report.

Risk factors for late mortality after endovascular repair of the thoracic aorta

2010-07-02

Objective: This study was conducted to identify risk factors for late mortality after thoracic endovascular aortic repair (TEVAR).Methods: A retrospective analysis of consecutive TEVAR was conducted. Medical record review, telephone contact, or query of the Social Security Death Index was used to determine 30-day and late survival. Late mortality was assessed with respect to patient characteristics at the time of the initial treatment, preoperative laboratory values, pathology, clinical presentation, and treatment adjuncts. Significant univariate predictors of death were entered into a multivariate Cox proportional hazards model.Results: From 1998 to 2009, 252 patients (149 men; mean age, 68 years) underwent TEVAR for degenerative thoracic aortic aneurysm (TAA, n = 143), type B dissection (n = 62), mycotic aneurysm (n = 13), traumatic disruption (n = 12), penetrating ulcer or intramural hematoma (n = 10), anastomotic pseudoaneurysm (n = 4), or other pathology (n = 8). The 30-day mortality was 9.5%, with stroke or spinal cord injury in 5.6%. Mean follow-up was 22 ± 22 months. Kaplan-Meier mean survival was 53 months. Predictors of late mortality by univariate analysis included age (P < .01), cardiac arrhythmia (P = .03), chronic obstructive pulmonary disease (P = .05), aneurysm diameter (P < .01), rupture (P < .01), debranching (P = .02), leukocytosis (white blood cell count > 10.0 × 103/μL; P < .01), albumin, (P < .01), and creatinine > 1.7 mg/dL (P = .01). Multivariate predictors of mortality included rupture (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.02-9.44; P = .03), debranching (HR, 2.20; 95% CI, 1.09-4.24; P = .03), preoperative leukocytosis (HR, 1.23; 95% CI, 1.09-1.39; P = .001), and aneurysm diameter (HR, 1.02; 95% CI, 1.01-1.03; P = .04). Subgroup analysis of patients undergoing TEVAR for asymptomatic, nonruptured TAA demonstrated that debranching (HR, 2.47; 95% CI, 1.13-5.39; P = .02), White blood cell count (HR, 1.19; 95% CI, 1.01-1.40; P < .04), and aneurysm diameter (HR, 1.03; 95% CI, 1.01-1.05, P < .01) remain independently predictive of late mortality.Conclusions: Preoperative leukocytosis, aneurysm diameter, and concurrent debranching independently predict late mortality irrespective of clinical presentation and may assist in risk stratification.

Discussion

2010-07-02

Dr H. Edward Garrett Jr, MD (Memphis, Tenn): I congratulate you on an excellent presentation and congratulate the Emory group for a robust experience with thoracic aortic endografting. This is a retrospective analysis of a single-center experience aimed at evaluating the risk factors contributing to 30-day and late mortality following thoracic aortic endografting for a wide variety of aortic pathologies.

Intermediate-term EVAR outcomes in octogenarians

2010-07-12

Objective: The utilization of endovascular abdominal aortic aneurysm repair (EVAR) in suitable patients has resulted in decreased perioperative morbidity and mortality. Octogenarians as a subgroup have been more readily offered EVAR, as it is less invasive, and therefore presumably better tolerated than conventional open aortic repair. The purpose of this study is to investigate periprocedural and late EVAR outcomes in octogenarians compared with patients less than 80 years of age.Methods: From January 2003 to May 2008, 322 patients underwent EVAR. A total of 117 octogenarians were compared with 205 patients less than 80 years of age. A retrospective review of the demographic data, aneurysm details, perioperative morbidity, mortality, and late outcomes were analyzed.Results: Octogenarians were significantly more likely to have a history of diabetes mellitus (51% vs 23%; P < .001), coronary artery disease (45% vs 32%; P = .0165), chronic obstructive pulmonary disease (44% vs 30%; P = .0113), and renal insufficiency (57% vs 31%; P < .0001). There were no significant differences in the rates of perioperative myocardial infarction, stroke, death, intestinal, or arterial ischemic complications between the two groups. Octogenarians had a significant higher rate of pulmonary complications (5.1% vs 1%; P < .03) and access-site hematomas (12% vs 2.4%; P = .001) than younger patients. When all significant perioperative morbidity was combined, octogenarians were twice as likely to develop complications following EVAR than younger patients (27.4% vs 11.7%; P = .001). At 5-year follow-up, younger patients were twice as likely to develop type II endoleaks.Conclusions: EVAR can be performed safely and effectively in octogenarians, and the incidence of major complications including myocardial infarction, stroke, and death is unchanged compared with younger patients. However, there is a significantly increased rate of access-site hematomas, pulmonary, and perioperative complications in octogenarians as a whole. Our findings suggest EVAR remains a suitable form of therapy in the elderly group provided there is an appropriate preoperative evaluation and perioperative monitoring following repair.

Discussion

2010-07-12

Dr Thomas Forbes (London, Ontario, Canada). With the absence of long-term outcomes in octogenarians, the authors set out to investigate periprocedural and long-term outcomes in these patients compared to younger patients. Over a recent 5-year period, they treated 320 patients, a third of which were over 80 years of age. Not only were these patients older, but they were also sicker, with higher degrees of coronary disease, diabetes, hypertension, COPD, and renal dysfunction.

Distribution of intimomedial tears in patients with type B aortic dissection

2010-07-02

Objective: Thoracic endovascular aortic repair is a promising means of treating patients with complicated type B aortic dissection by excluding the intimomedial tears. This study aims to characterize the location of tears and to propose a classification of type B aortic dissections based on these findings.Methods: Advanced protocols in computed tomography scans of patients with type B aortic dissection were used to identify the size and location of intimomedial tears in relation to the origin of the left subclavian artery. Aortic imaging details in 72 un-operated patients were used as a reference standard. From 1999 to 2005, 44 patients underwent primary endovascular treatment for complications of type B aortic dissection.Results: Each patient had an average of 2.8 ± 2.11 intimomedial tears. The median intimomedial tear surface area was 0.63 cm2. The presence of ≥3 or ≥5 intimomedial tears in the descending thoracic aorta did not correlate with aortic branch malperfusion (P > .05). Thirteen of 26 (50%) patients with a tear >1.9 cm2 had aortic branch malperfusion (P = .032). Ten of 14 (71%) patients with a tear >4.86 cm2 (mean plus one standard deviation) had aortic branch malperfusion (P = .002). The location of tears ranged from -6 mm to +459.2 mm from the left subclavian artery orifice: 80.5% (n = 99) of these tears were above the reference origin of the celiac artery. Eight of 13 patients (62%) with a tear distal to 282 mm (the orifice of the celiac artery) had aortic branch malperfusion in (P = .04). A classification for the location of intimomedial tears is proposed with potential clinical relevance to endovascular repair: type 1 has no identifiable tears; type 2 has one or more tears with no tears distal to the orifice of the celiac artery; type 3 has tears involving the branch vessels of the abdominal aorta; and type 4 has intimomedial tears distal to the aortic bifurcation.Conclusions: Characterization and location of intimomedial tears using computed tomography (CT) imaging is feasible and represents an important step in the management of type B aortic dissection. The location and surface area of tears is associated with malperfusion. Based on the proposed classification and anatomic reference data, three out of every four patients may have a favorable constellation of intimomedial tears (type 1 or 2) that would be amenable to endovascular repair and reverse aortic remodeling. The clinical correlation will be established in upcoming studies.

Cerebral reserve is decreased in elderly patients with carotid stenosis

2010-07-12

Objectives: Octogenarians and even patients over 70 years old have unexplained poor outcomes with carotid angioplasty and stenting (CAS). We sought to evaluate whether older patients may have compromised intracranial collaterals and cerebral reserve and be intolerant to otherwise clinically silent emboli generated during CAS.Methods: One thousand twenty-four cerebral blood flow (CBF) studies performed between 1991 and 2001 with stable xenon computed tomography scans (Xe/CT) were reviewed. CBF was measured before and after 1 gm intravenous acetazolamide (ACZ), a cerebral vasodilator. The normal response to ACZ is an increase in CBF. In areas of significant compromise of cerebral reserve (CR), CBF drops, representing a “steal” phenomenon. CBF changes were categorized as normal or abnormal and correlated with age, gender, cerebral symptoms, and with intracranial, carotid, or vertebral artery disease. Logistic regression was used to determine the effect of age on CR in the entire group and a subgroup of 179 patients with significant carotid stenosis of >50%.Results: Nine hundred sixteen studies were suitable for analysis. Carotid occlusion was predictive of decreased reserve (OR, 3.9; P = .03) regardless of age. There was also a trend toward lower reserve with severe carotid stenosis >70% (OR, 3) and in women (OR, 1.8; P = .08). Age ≥70 had no effect on reserve in the overall heterogeneous population with and without carotid disease and neither did a history of stroke, carotid, or intracranial stenosis. However, in 179 patients with significant carotid stenosis, age ≥70 was predictive of poor reserve (OR, 2.7; P = .03) and so was the presence of peripheral vascular disease (OR, 3.7; P = .03). A trend toward decreased reserve was also seen in women (OR, 2.3; P = .08).Conclusions: Age ≥70 is associated with poor cerebral reserve in patients with significant carotid stenosis as measured by CBF response to an ACZ challenge. Thus, patients ≥70 may be more sensitive to minor cerebral emboli, which may be one factor explaining their higher risk of stroke during CAS.

Discussion

2010-07-12

Dr Philip Goodney (Lebanon, NH). I think this is an elegant investigation into the pathophysiology underlying higher stroke rates following carotid stenting in patients of older age groups. I think these findings are intriguing, and I have several questions toward this end.

CAPTURE 2 risk-adjusted stroke outcome benchmarks for carotid artery stenting with distal embolic protection

2010-06-24

Objective: Many medical procedures undergo rapid evolution and process of care improvements after introduction. National outcome standards are useful to help physicians, institutions, and other stakeholders evaluate the quality of their programs and take action when suboptimal outcomes are identified. The purpose of this analysis was to derive contemporary risk-adjusted stroke rates from a large, contemporary, independently assessed outcome database within 30 days after carotid artery stenting (CAS) in the United States.Methods: The second phase of carotid ACCULINK/ACCUNET post approval trial to uncover rare events (CAPTURE 2) is an ongoing prospective, multicenter, clinical trial conducted to assess CAS outcomes in the general practice setting after device approval for high surgical risk patients (symptomatic with >50% stenosis or asymptomatic with >80% stenosis). A neurologist examined the patients before the procedure, at 1 day and 30 days after CAS. The primary endpoint was a composite of death, any stroke, or myocardial infarction (MI) within the periprocedural period. Strokes and neurologic events suspected to be strokes were adjudicated by an independent clinical events adjudication committee. Logistic regression analysis including stepwise logistic and multivariable modeling was performed to determine clinical predictors of periprocedural stroke outcome and generate a parsimonious model that could be used for a clinical standard.Results: Five thousand two hundred ninety-seven consecutive patients (5297) had CAS performed by 459 physicians at 186 sites before the data cutoff of January 10, 2009. The 30-day rate of stroke was 2.7% (95% confidence interval [CI], 2.3–3.2). Multivariable predictors of periprocedural stroke included age, symptomatic status, and dwell time of embolic protection device. A parsimonious model Pi = 1/(1+e −(−3.83 + 0.51 × (symptomatic) + 0.31 × (age ≥80) + 0.62 × (age ≥80 × symptomatic)), including symptomatic and octogenarian status and the term of the interaction of the two, was established based on consideration of clinical predictors, clinical interaction, and practicability.Conclusion: CAS outcomes in patients at high surgical risk have comparable periprocedural outcomes to published randomized trials of endarterectomy for patients at standard surgical risk. A model is presented for calculating a contemporary national standard for risk-adjusted stroke rates. Quality improvement measures could be based on relative performance to this benchmark and could improve overall outcomes for patients undergoing CAS.

Four-year randomized prospective comparison of percutaneous ePTFE/nitinol self-expanding stent graft versus prosthetic femoral-popliteal bypass in the treatment of superficial femoral artery occlusive disease

Karen McQuade, Dennis Gable, Greg Pearl, Brian Theune, Steve Black — 2010-07-02

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

Discussion

2010-07-02

Dr John F. Eidt (Little Rock, Ark). This is indeed a unique randomized trial comparing above knee synthetic bypass to the Gore stent graft. Of note, the authors report comparable performance between these two treatment groups at 4 years. There is a trend favoring stent grafts larger than 5 mm in diameter.

Histologic atherosclerotic plaque characteristics are associated with restenosis rates after endarterectomy of the common and superficial femoral arteries

2010-06-07

Objectives: This study assessed the predictive value of histologic plaque characteristics for the occurrence of restenosis after femoral artery endarterectomy.Background: It would be advantageous if patients at increased risk for restenosis after arterial endarterectomy could be identified by histologic characteristics of the dissected plaque. Differences in atherosclerotic plaque composition of the carotid artery have been associated with restenosis rates after surgical endarterectomy. However, whether atherosclerotic plaque characteristics are also predictive for restenosis in other vascular territories is unknown.Methods: Atherosclerotic plaques of 217 patients who underwent a common femoral artery endarterectomy (CFAE; n = 124) or remote superficial femoral artery endarterectomy (RSFAE; n = 93) were examined and scored microscopically for the presence of collagen, macrophages, smooth muscle cells, lipid core, intraplaque hemorrhage, and calcifications. The 12-month restenosis rate was assessed using duplex ultrasound imaging (peak systolic velocity [PSV] ratio ≥2.5).Results: The 1-year restenosis rate was 66% (61 of 93) after RSFAE compared to 21% (26 of 124) after CFAE. Plaque with characteristics of high collagen and smooth muscle cell content were positively associated with the occurrence of restenosis, with odds ratios (ORs) of 2.90 (95% confidence interval [CI], 1.82-4.68) and 2.20 (1.50-3.20) for superficial femoral artery (SFA) and common femoral artery (CFA), respectively. SFA plaques showed significantly heavier staining for collagen (69% vs 31% for CFA; P < .001) and smooth muscle cells (64% vs 36% for CFA; P < .001). After multivariate analysis, the operation type (CFAE or RSFAE), gender, and the presence of collagen were independent predictive variables for restenosis after endarterectomy of the CFA and SFA.Conclusion: Plaque composition of the CFA and SFA differs. Furthermore, the dissection of a fibrous collagen-rich plaque is an independent predictive variable for restenosis after endarterectomy of the CFA and SFA.

The impact of socioeconomic factors on outcome and hospital costs associated with femoropopliteal revascularization

2010-07-05

Introduction: Within the context of healthcare system reform, the cost efficacy of lower extremity revascularization remains a timely topic. The impact of an individual patient's socioeconomic status represents an under-studied aspect of vascular care, especially with respect to longitudinal costs and outcomes. The purpose of this study is to examine the relationship between socioeconomic status and clinical outcomes as well as inpatient hospital costs.Methods: A retrospective femoropopliteal revascularization database, which included socioeconomic factors (household income, education level, and payor status), in addition to standard demographic, clinical, anatomical, and procedural variables were analyzed over a 3-year period. Patients were stratified by income level (low income [LI] <200% federal poverty level [$42,400 for a household of 4], and higher income [HI] >200% federal poverty level) and revascularization technique (open vs endovascular) and analyzed for the endpoints of primary assisted patency, amortized cost-per-day of patency, and limb salvage. Data were analyzed with univariate and multivariate techniques.Results: A total of 187 cases were identified with complete data for analysis, 146 in the LI and 41 in the HI cohorts. LI patients differed from HI patients by mean age (66.2 ± 1.0 vs 61.8 ± 1.5 years, P = .04), high school graduate rate (51.4% vs 85.4%, P < .001), presence of tissue loss (30.1% vs 14.6%, P = .05), female gender (43.7% vs 22.0%, P = .01) and preoperative statin use (45.8% vs 75.6%, P < .001). There were no differences with respect to other comorbidities including smoking status, presence of diabetes, renal insufficiency, anatomic factors or treatment modality (open vs endovascular). Ninety-seven patients underwent endovascular revascularization. The following outcomes were noted in the endovascular subset of LI and HI patients respectively: primary assisted patency (66% vs 71%, P = NS) and 12-month cost-per-day of patency ($166.30 ± 77.40 vs $22.45 ± 12.45, P = .05). Ninety-eight patients underwent open revascularization, with the following outcomes in LI and HI patients respectively: primary assisted patency (78% vs 86%, P = NS) and 12-month cost-per-day of patency ($319.43 ± 225.44 vs $40.47 ± 4.63, P = .07). Of the 77 patients with critical limb ischemia, 19 underwent eventual amputation. Multivariate analysis demonstrated that income above 100% of the federal poverty line was protective against limb loss (odds ratio 0.06, 95% confidence interval 0.01-0.51, P < .001).Conclusion: Income level correlates with advanced presentation, advanced age, and lack of statin use. Although primary assisted patency rate is not affected by income status, an increased cost-per-day of patency and inferior limb salvage is found in lower income patients.

Discussion

2010-07-05

Dr Julie A. Freischlag (Baltimore, Md). This retrospective analysis of the impact of one's socioeconomic status on the cost and outcomes of lower extremity bypass as with most provocative studies raises more questions than it answers. It also does not include a non-operative and/or exercise group which I believe would have the lowest cost-per-day as one of its many advantages.

Mid-term clinical outcome and predictors of vessel patency after femoropopliteal stenting with self-expandable nitinol stent

2010-06-23

Background: Long-term clinical outcomes after femoropopliteal (FP) stenting with nitinol stents have not yet been clear. We investigated the mid-term efficacy of FP stenting with nitinol stents.Methods: This study was a multicenter retrospective study. From April 2004 to December 2008, 511 consecutive patients (639 limbs; mean age 71 ± 7 years; 71% male) who underwent successful FP stenting with nitinol stents for de novo lesions were retrospectively selected and analyzed in this multicenter study. All patients had a minimum follow-up of 6 months. Restenosis was defined as >2.4 of peak systolic velocity ratio by duplex or >50% stenosis by angiogram. Primary patency was defined as treated vessels without restenosis and repeat revascularization. Secondary patency was defined as target vessels that become totally occluded and are reopened by repeat revascularization.Results: Sixty-one percent of the patients had diabetes, 76% were claudicant, and 20% were on hemodialysis. Mean lesion length was 151 ± 75 mm. Mean follow-up period was 22 ± 11 months. Primary patency was 79.8%, 66.7%, and 63.1%, and secondary patency was 90.4%, 87.3%, and 86.2% at 1, 3, and 5 years, respectively. During the follow-up period, 53 patients (10%) died. Of them, cardiovascular death was 38% and stent fracture had occurred in 14%. On multivariate analysis by Cox proportional hazard ratio, cilostazol administration (hazard ratio [HR], 0.52;P < .0001), stent fracture (HR, 1.6; P = .03), hemodialysis (HR, 1.7; P = .01), and Trans Atlantic Inter-Society Consensus (TASC) II class C/D (HR, 2.4; P < .0001) were the independent predictors of primary patency after successful FP stenting.Conclusion: Clinical efficacy of nitinol stent implantation for FP disease was favorable for up to 5 years.

Arm vein conduit vs prosthetic graft in infrainguinal revascularization for critical leg ischemia

2010-07-08

Background: One-piece great saphenous vein (GSV) is the conduit of choice in infrainguinal revascularizations for critical limb ischemia (CLI). Unfortunately, adequate length of usable GSV is not always available. Despite inferior patency rates compared with GSV, prosthetic and arm vein conduits are generally considered usable. The purpose of this study was to compare the outcome of infrainguinal arm vein and prosthetic bypass.Material and methods: We retrospectively reviewed 290 consecutive infrainguinal bypasses for CLI using arm vein conduit (n = 130) or prosthetic graft (n = 160) during January 2000 and December 2006 at our institution. The groups were compared for risk factors, indication for surgery, and runoff score. Survival, leg salvage, and patency rates were calculated with the Kaplan-Meier method.Results: Median surveillance time was 35 months (range 0-118 months). The age, gender, and usual risk factors were similar in arm vein and prosthetic groups, except cerebrovascular disease that was more common in the prosthetic group (P = .011). Indication for surgery was CLI. In the arm vein group, more than two-thirds (70.2%) of the procedures were for ischemic ulcer or gangrene, whereas in the prosthetic group the main indication was ischemic rest pain (51.3%). When the outcome of femoropopliteal bypasses was analyzed, the difference between groups was not statistically significant. However, in infrapopliteal revascularizations primary patency, assisted primary patency, and secondary patency rates at 3 years were significantly better in the arm vein group: 28.3% (SE ± 6.3%) vs 9.6% (SE ± 8.1%) (P = .031), 56.8% (SE ± 6.6%) vs 10.4% (SE ± 8.7%) (P = .000), and 57.4% (SE ± 6.6) vs 11.2% (SE ± 9.3%) (P = .000), respectively. Leg salvage and survival at 3 years were 75.0% (SE ± 4.9%) vs 57.1% (SE ± 8.8%) (P = .005) and 58.8% (SE ± 5.1%) vs 39.5% (SE ± 7.7%) (P = .007), respectively.Conclusion: Arm vein conduits, even when spliced, are superior to prosthetic grafts in terms of midterm assisted primary patency, secondary patency, and leg salvage in infrapopliteal bypasses for CLI.

Leg strength predicts mortality in men but not in women with peripheral arterial disease

2010-07-02

Objective: To establish associations between leg strength and mortality in men and women with lower extremity peripheral arterial disease (PAD).Methods: This was an observational, prospective study of 410 men and women with PAD aged 55 and older recruited from Chicago-area medical centers and followed for a mean of 60 months. The participants were followed for a mean of 60.0 months. Isometric knee extension, knee flexion, hip extension, and hip flexion were measured at baseline. Primary outcomes were all-cause and cardiovascular disease mortality. Cox proportional hazards models were used to assess relations between leg strength and all-cause and cardiovascular disease mortality among men and women, adjusting for age, race, comorbidities, physical activity, smoking, body mass index, and the ankle brachial index.Results: Among the 246 male participants, poorer baseline strength for knee flexion (P trend = .029), knee extension (P trend =.010), and hip extension (P trend = .013) were each associated independently with higher all-cause mortality. Poorer strength for knee flexion (P trend = .042) and hip extension (P trend = .029) were associated with higher cardiovascular mortality. Compared with those in the fourth (best) baseline knee flexion quartile, hazard ratios for all-cause and cardiovascular disease mortality among men in the first (poorest) knee flexion quartile were 2.23 (95% confidence interval [CI], 1.02-4.87; P = .045) and 4.20 (95% CI, 1.12-15.79; P = .044), respectively. No significant associations of leg strength and all-cause mortality were identified among women.Conclusions: Poorer leg strength is associated with increased mortality in men, but not women, with PAD. Future study is needed to determine whether interventions that increase leg strength improve survival in men with PAD.

An elevated neutrophil-lymphocyte ratio independently predicts mortality in chronic critical limb ischemia

2010-06-23

Background: Atherogenesis represents an active inflammatory process with leucocytes playing a major role. An elevated white blood cell count has been shown to be predictive of death in coronary artery disease patients. The aim of this study was to examine the predictive ability of neutrophil count and neutrophil/lymphocyte ratio for predicting survival in patients with critical lower limb ischemia (CLI).Methods: All patients admitted to a single vascular unit with CCLI were identified prospectively over a 2-year period starting from January 2005. Patient demographics, clinical history, comorbidity, and risk factors for peripheral vascular disease were documented. The white blood count and differential cell count at admission was recorded. Overall, patient mortality was studied as the primary outcome.Results: One hundred forty-nine patients were identified, with a median age of 72 years (Interquartile range [IQR], 65.7-81). A neutrophil-lymphocyte ratio (NLR) of ≥5.25 was taken as the cutoff, based upon the receiver-operating-characteristic.The median follow up was 8.7 months (IQR, 3.1-16). During the follow-up period, there have been 62 deaths (43.4%). An elevated neutrophil/lymphocyte ratio and a high troponin level (>0.1) were found to be the only two factors independently associated with shorter survival on multivariate analysis using the Cox proportional hazards model.Conclusions: This study suggests that an elevated NLR can identify a poor-risk subset of patients among those being treated for critical limb ischemia. This simple, inexpensive test may, therefore, add to risk stratification of these high-risk patients.

Younger women with symptomatic peripheral arterial disease are at increased risk of depressive symptoms

2010-06-24

Objectives: Gender disparities, particularly among young women with cardiovascular disease, are a growing cause for concern. Depression is a prevalent and prognostically important comorbidity in peripheral arterial disease (PAD), but its prevalence has not been described as a function of gender and age. Therefore, we compared depressive symptoms at the time of PAD diagnosis and 6 months later by gender and age in PAD patients.Methods: The study enrolled 444 newly diagnosed patients with PAD (32% women) from two Dutch vascular outpatient clinics. Patients' depressive symptoms were assessed with the 10-item Center for Epidemiological Studies Depression Scale (CES-D) at baseline and 6 months later (CES-D scores ≥4 indicate significant depressive symptoms). Logistic regression models were constructed to evaluate the relationship among four gender-age groups (women <65 and ≥65 years; men <65 and ≥65 years [reference category]) and baseline and 6-month follow-up depressive symptoms.Results: Initially, 33% of women <65 years had significant depressive symptoms, and 6 months later, significant depressive symptoms had developed in 19% of the other younger women. These rates were much higher than other gender-age groups (range at baseline, 11%-16%; 6-month incidence, 6%-10%; P ≤ .03). Adjusting for demographics and clinical factors, women <65 years experienced a fourfold greater odds of baseline (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.2-8.7) and follow-up depressive symptoms (OR, 4.1; 95% CI, 2.0-8.4) compared with men ≥65 years, whereas other gender-age groups were not at risk. Additional adjustment for change in the ankle-brachial index did not explain the increased depression risk in younger women (OR, 3.5; 95% CI, 1.2-10.2).Conclusions: Significant depressive symptoms are more common in younger women with PAD than in other gender-age groups, both at the time of diagnosis and 6 months later. To eradicate gender-based disparities in PAD, depression screening and monitoring in younger women may be an important direction for future research and intervention.

A randomized, controlled trial of endovenous thermal ablation using the 810-nm wavelength laser and the ClosurePLUS radiofrequency ablation methods for superficial venous insufficiency of the great saphenous vein

2010-07-20

Background: Great saphenous vein (GSV) incompetence is the most common cause of superficial venous insufficiency. Radiofrequency catheter ablation (RFA) is superior to conventional ligation and stripping, and endovenous laser treatment (EVL) has emerged as an effective alternative to RFA. This randomized study evaluated RFA and EVL for superficial venous insufficiency due to GSV incompetence and compared early and 1-year results.Methods: Between June 2006 and May 2008, patients with symptomatic primary venous insufficiency due to GSV incompetence were randomized to RFA or EVL. Patients with bilateral disease were randomized for treatment of the first leg and received the alternative method on the other. Pretreatment examination included a leg assessment using the Venous Clinical Severity Score (VCSS) and CEAP classification. Patients completed the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2). RFA was performed with the ClosurePlus system (VNUS Medical Technologies, Sunnyvale, Calif). EVL was performed with the EVLT system (AngioDynamics Inc, Queensbury, NY). Early (1-week and 1-month) postoperative results of pain, bruising, erythema, and hematoma were recorded. Duplex ultrasound (DU) imaging was used at 1 week and 1 year to evaluate vein status. VCSS scores and CEAP clinical class were recorded at each postoperative visit, and quality of life (QOL) using CIVIQ2 was assessed at 1 month and 1 year.Results: The study enrolled 118 patients (141 limbs): 46 (39%) were randomized to RFA and 48 (40%) to EVL, and 24 (20%) had bilateral GSV incompetence. At 1 week, one patient in the RFA group had an open GSV and was deemed a failure. More bruising occurred in the EVL group (P = .01) at 1 week, but at 1 month, there was no difference in bruising between groups. At 1 year, DU imaging showed evidence of recanalization with reflux in 11 RFA and 2 EVL patients (P = .002). The mean VCSS score change from baseline to 1 week postprocedure was higher for RFA than EVL (P = .002), but there was no difference between groups at 1 month (P = .07) and 1 year (P = .9). Overall QOL mean score improved over time for all patients (P < .001). CEAP clinical class scores of ≥3 were recorded in 21 RFA (44%) and 24 EVL patients (44%) pretreatment, but at 1-year, 9 RFA (19%) and 12 EVL patients (24%) had scores of ≥3 (P < .001). This represented a significant improvement in all patients compared with baseline.Conclusion: Both methods of endovenous ablation effectively reduce symptoms of superficial venous insufficiency. EVL is associated with greater bruising and discomfort in the perioperative period but may provide a more secure closure over the long-term than RFA.

Symptomatic perioperative venous thromboembolism is a frequent complication in patients with a history of deep vein thrombosis

2010-06-17

Objectives: Patients who undergo surgery are at risk for venous thromboembolism (VTE), and a history of prior deep vein thrombosis (DVT) increases that risk. This study determined the incidence and risk factors for symptomatic perioperative VTE in patients with a prior diagnosis of DVT.Methods: All lower extremity DVTs, diagnosed between January 2002 and December 2006, were identified through a vascular database. Patients who had subsequent surgery were reviewed. The following data were evaluated: location of DVT, time interval between DVT and surgery, type of surgery, common clinical VTE risk factors, postoperative venous duplex scans, computed tomography (CT) scans of the chest, and ventilation-perfusion scans.Results: A total of 372 patients with prior DVT underwent 1081 subsequent surgical procedures. One hundred nine patients undergoing 211 procedures had a follow-up venous duplex scan within 30 days after surgery. Of them, 46% received an inferior vena caval (IVC) filter, and pulmonary emboli were diagnosed in 3 patients (<1%). Overall, 24% of the patients developed DVT extension or new-site DVT in the perioperative period. The median time interval between the original DVT and surgery was 1.5 weeks in patients with DVT recurrence and 4 weeks in patients without recurrence (P = .22, Mann–Whitney). High-risk surgeries were associated with a >three-fold increased risk for recurrence, when compared with low-risk procedures (34% vs 11%; P = .009, χ2). Perioperative VTE recurrence was not influenced by the location of the original thrombus or other VTE risk factors.Conclusion: In patients with prior DVT, perioperative symptomatic recurrence is common and is associated with high-risk procedures. A longer time interval between a DVT episode and subsequent surgery may decrease the risk of recurrence, but large clinical trials are needed to confirm this. Further prospective evaluations are needed to identify and treat patients at greatest risk for recurrence.

Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis

2010-09-01

Background: Axillosubclavian vein thrombosis, also known as Paget-Schroetter syndrome, is a rare presentation of thoracic outlet syndrome (TOS) representing approximately 5% of all cases. Conventional management consists of routine anticoagulation, operative decompression via first rib resection and scalenectomy (FRRS), and, recently, thrombolysis. The purpose of our study was to retrospectively review our experience with this condition and compare the effectiveness of preoperative endovascular intervention with thrombolysis and venoplasty to anticoagulation alone in those undergoing FRRS to preserve subclavian vein patency.Methods: A retrospective review was conducted for all venous TOS patients from July 2003 to May 2009 from a prospectively maintained database. Preoperative clinic notes were reviewed to allow stratification into two groups. One group consisted of patients undergoing preoperative endovascular intervention with thrombolysis and venoplasty, while the other group consisted of patients managed medically with anticoagulation alone prior to FRSS. Operative notes, postoperative venograms, and postoperative duplex imaging results were reviewed for presence of recanalization, chronic nonocclusive thrombus, or continued occlusion.Results: One hundred three patients had 110 FRRS for subclavian vein thrombosis (53 men, 50 women), seven of which had contralateral FRRS for thrombosis. The cohort averaged 31 years of age (range, 16-54 years) with an overall, mean follow-up time of 16 months (range, 1-52 months). Of the 110 veins evaluated, 45 underwent endovascular intervention (thombolysis, with or without venoplasty) prior to FRRS, and at 1 year, 41 (91%) were patent with improvement of symptoms. In the 65 veins on anticoagulation alone, 59 (91%) ultimately were patent, with symptomatic improvement in all. Overall, 91% (100/110) of subclavian veins were patent in patients completing follow-up, were asymptomatic, and back to their previous active lifestyle.Conclusions: Preoperative endovascular intervention offered no benefit over simple anticoagulation prior to FRRS, since the use of thrombolysis prior to FRRS, regardless of need for postoperative venoplasty, had little impact on overall rates of patency. The optimal treatment algorithm may merely be routine anticoagulation for all effort thrombosis patients prior to FRRS followed by venography with venoplasty if needed. The role of thrombolysis for Paget-Schroetter syndrome should be further investigated in randomized trials.

Discussion

2010-09-01

Dr L. Richard Sprouse (Chattanooga, Tenn). Thank you. First of all, I would like to thank the authors for providing me with this manuscript before the meeting. I haven't noticed any major changes compared to the original abstract that was submitted to the Southern Association for Vascular Surgery, and I would like to congratulate Dr Guzzo on an outstanding presentation.

Impact of obesity on venous hemodynamics of the lower limbs

2010-06-24

Background: Obesity is a risk factor for chronic venous insufficiency and venous thromboembolism. The aim of this study was to compare venous flow parameters of the lower limbs assessed by duplex ultrasound scanning in obese and nonobese individuals according to body mass index (BMI).Methods: Venous hemodynamics were studied in a prospective cohort study in nonobese (BMI <25 kg/m2) and obese individuals (BMI >30 kg/m2). Diameter, flow volume, peak, mean, and minimum velocities were assessed.Results: The study examined 36 limbs in 23 nonobese individuals and 44 limbs in 22 obese individuals. The diameter of the femoral vein was significantly greater in obese (8.5 ± 2.2 mm) vs nonobese (7.1 ± 1.6 mm; P = .0009) limbs. Venous peak and minimum velocities differed between nonobese and obese individuals (14.8 ± 7.2 vs 10.8 ± 4.8 cm/s [P = .0071] and 4.0 ± 3.6 vs 1.7 ± 6.3 cm/s [P = .056]). Calculation of venous amplitude and shear stress showed significantly higher values in nonobese vs obese (18.8 ± 9.4 vs 12.5 ± 9.3 cm/s [P = .003] and 2.13 ± 2.2 dyn/cm2 vs 1.6 ± 2.7 dyn/cm2 [P = .03]). Spearman rank correlation revealed a significant inverse correlation between waist-to-hip ratios and waist circumference and venous peak velocity, mean velocity, velocities amplitude (peak velocity-minimum velocity), and shear stress.Conclusion: Lower limb venous flow parameters differ significantly between healthy obese and nonobese individuals. These findings support the mechanical role of abdominal adipose tissue potentially leading to elevated risk for both venous thromboembolism and chronic venous insufficiency.

Vascular changes at the puncture segments of arteriovenous fistula for hemodialysis access

2010-07-12

Objective: Repeated puncture is a mechanical injury to the hemodialysis accesses. We systemically observed the vascular changes at the puncture segments of arteriovenous fistulas.Methods: The native arteriovenous fistulas in 104 patients on maintenance hemodialysis using the buttonhole technique for puncture were studied. We used the duplex scan to observe the intimal lesions, the maximal diameters at the arterial and venous puncture segments, and the references.Results: Intimal lesions were found in 42% and 40% of the arterial and venous puncture segments, none of which resulted in significant luminal stenosis. The differences between diameters at the arterial or venous puncture segments and the corresponding references were significant (arterial, 11.07 ± 4.45 vs 6.85 ± 2.35 mm, P < .001; venous, 8.82 ± 4.13 vs 5.54 ± 2.22 mm, P < .001). All segments, except only three arterial and four venous puncture segments, were larger than the corresponding references. The degree of vascular dilatation, defined as the diameter difference between the puncture segments and the references calibrated by the reference diameter, were 64.1 ± 49.6% at arterial puncture segments and 59.9 ± 42.2% at venous segments. Multivariate analysis revealed that the patient age and the puncture duration were strongly correlated with the degree of vascular dilatation at both the arterial (P = .018 and .007, respectively) and venous puncture segments (P = .020 and .011, respectively).Conclusion: Puncture of arteriovenous fistula using a buttonhole technique resulted in a consistent vascular dilatation and moderately high incidence of intimal thickness, but no significant luminal stenosis was found.

The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients

2010-06-07

Objective: The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We compared the accuracy of the RCRI with a new, vascular surgery-specific model developed from patients within the Vascular Study Group of New England (VSGNE).Methods: We studied 10,081 patients who underwent nonemergent carotid endarterectomy (CEA; n = 5293), lower extremity bypass (LEB; n = 2673), endovascular abdominal aortic aneurysm repair (EVAR; n = 1005), and open infrarenal abdominal aortic aneurysm repair (OAAA; n = 1,110) within the VSGNE from 2003 to 2008. First, we analyzed the ability of the RCRI to predict in-hospital major adverse cardiac events, including myocardial infarction (MI), arrhythmia, or congestive heart failure (CHF) in the VSGNE cohort. Second, we used a derivation cohort of 8208 to develop a new cardiac risk prediction model specifically for vascular surgery patients. Chi-square analysis identified univariate predictors, and multivariate logistic regression was used to develop an aggregate and four procedure-specific risk prediction models for cardiac complications. Calibration and model discrimination were assessed using Pearson correlation coefficient and receiver operating characteristic (ROC) curves. The ability of the model to predict cardiac complications was assessed within a validation cohort of 1873. Significant predictors were converted to an integer score to create a practical cardiac risk prediction formula.Results: The overall incidence of major cardiac events in the VSGNE cohort was 6.3% (2.5% MI, 3.9% arrhythmia, 1.8% CHF). The RCRI predicted risk after CEA reasonably well but substantially underestimated risk after LEB, EVAR, and OAAA for low- and higher-risk patients. Across all VSGNE patients, the RCRI underestimated cardiac complications by 1.7- to 7.4-fold based on actual event rates of 2.6%, 6.7%, 11.6%, and 18.4% for patients with 0, 1, 2, and ≥3 risk factors. In multivariate analysis of the VSGNE cohort, independent predictors of adverse cardiac events were (odds ratio [OR]) increasing age (1.7-2.8), smoking (1.3), insulin-dependent diabetes (1.4), coronary artery disease (1.4), CHF (1.9), abnormal cardiac stress test (1.2), long-term β-blocker therapy (1.4), chronic obstructive pulmonary disease (1.6), and creatinine ≥1.8 mg/dL (1.7). Prior cardiac revascularization was protective (OR, 0.8). Our aggregate model was well calibrated (r = 0.99, P < .001), demonstrating moderate discriminative ability (ROC curve = 0.71), which differed only slightly from the procedure-specific models (ROC curves: CEA, 0.74; LEB, 0.72; EVAR, 0.74; OAAA, 0.68). Rates of cardiac complications for patients with 0 to 3, 4, 5, and ≥6 VSG risk factors were 3.1%, 5.0%, 6.8%, and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, and 10.1% in the validation cohort. The VSGNE cardiac risk model more accurately predicted the actual risk of cardiac complications across the four procedures for low- and higher-risk patients than the RCRI. When the VSG Cardiac Risk Index (VSG-CRI) was used to score patients, six categories of risk ranging from 2.6% to 14.3% (score of 0-3 to 8) were discernible.Conclusions: The RCRI substantially underestimates in-hospital cardiac events in patients undergoing elective or urgent vascular surgery, especially after LEB, EVAR, and OAAA. The VSG-CRI more accurately predicts in-hospital cardiac events after vascular surgery and represents an important tool for clinical decision making.

Desmuslin gene knockdown causes altered expression of phenotype markers and differentiation of saphenous vein smooth muscle cells

Ying Xiao, Zhibin Huang, Henghui Yin, Hui Zhang, Shenming Wang — 2010-06-23

Objective: Phenotypic alterations of vascular smooth muscle cells (VSMCs) appear critical to the development of primary varicose veins. Previous study indicated desmuslin, an intermediate filament protein, was differentially expressed in smooth muscle cells (SMCs) isolated from varicose veins; thus, it was naturally hypothesized that altered desmuslin expression might in turn affect the functioning of VSMCs, leading to the phenotypic alterations and varicose vein development.Methods: In this study, expression of desmuslin in normal human saphenous vein SMCs was knocked down using small interfering RNA (siRNA), and control cells were treated with a scrambled siRNA sequence. The levels of several phenotypic markers including smooth muscle (SM) α-actin and smooth muscle myosin heavy chain (SM-MHC) were assessed. Collagen formation, matrix metalloproteinase expression (MMP-2), and cytoskeletal and morphological changes were also examined.Results: SMCs treated with desmuslin siRNA exhibited significantly increased levels of collagen synthesis and MMP-2 expression and decreased expression levels of SM α-actin, SM-MHC, and smoothelin and exhibited disassembly of actin stress fibers when compared with the control cells. Changes in cell morphology and actin fiber networks in VSMCs treated with desmuslin siRNA were consistent with a lower degree of differentiation.Conclusions: These results indicated desmuslin expression is required for the maintenance of VSMC phenotype. Decreased desmuslin expression may affect differentiation of VSMCs and ultimately contribute to the development of varicose veins.Clinical Relevance: Primary varicose veins are a frequent and refractory disease of the peripheral veins. Improved understanding of the cellular and molecular mechanisms involved may allow the identification of additional targets for pharmacologic intervention.

Haptoglobin 2-1 phenotype predicts rapid growth of abdominal aortic aneurysms

2010-06-07

Background: Haptoglobin (Hp) polymorphism is associated with the prevalence and clinical evolution of many inflammatory diseases and atherosclerosis. Circulating neutrophils and neutrophil-associated proteases are an important initial component of experimental abdominal aortic aneurysm (AAA) formation. Elastase and C-reactive protein (CRP) levels are elevated in patients with AAAs. This study assessed the relationship between AAA expansion and Hp phenotypes, neutrophil count, elastase, and CRP levels.Methods: Eighty-three consecutive AAA patients underwent annual ultrasound scans. Three major Hp phenotypes (1-1, 2-1, and 2-2) were determined, and the neutrophil count, serum elastase, and high-sensitivity (hs) CRP levels were measured at the initial examination. After initial screening, patients were rescanned at 6- to 12-month intervals up to a period of 2 to 7 years. The mean yearly growth of the AAA largest transverse diameter was estimated for each group of Hp patients. The results are presented as median (interquartile range).Results: Hp 2-1 patients had a significantly higher growth rate (3.69 [2.40] mm/y) of AAA compared with patients with Hp 2-2 (1.24 [0.79], P < .00001) and Hp 1-1 (1.45 [0.68], P = .00004). This association remained significant in the multivariate analysis. Elevated elastase serum activity was also evident in AAA patients with Hp 2-1 (0.119 [0.084] arbitrary units) in contrast to Hp 2-2 (0.064 [0.041], P < .00001) and Hp 1-1 (0.071 [0.040], P = .0006) patients. CRP serum levels (mg/L) were significantly higher in patients with Hp 2-1 (7.2 [7.1]) than in Hp 2-2 (3.4 [3.1], P = .0058) and Hp 1-1 (2.8 [4.1], P = .044). The neutrophil count was not significantly different among Hp groups.Conclusions: The Hp 2-1 phenotype showed a strong association with increased rates of the expansion of AAAs and may be a useful independent predictor of growth rate. Further large follow-up studies will be needed to investigate the pathomechanisms of association and the role of elastase and inflammation in the progression of AAA.Clinical Relevance: Elective surgical or endovascular repair is recommended for large aneurysms, whereas small aneurysms are managed by watchful waiting. The diameter and rate of growth of the AAA are the most important determinants of the risk of rupture and in deciding when elective repair is justified. In the present study, the Hp 2-1 phenotype predicted rapid aneurysm expansion. This may have implications for the frequency of follow-up and timing of repair of AAA in patients with the Hp 2-1 phenotype.

Perioperative platelet and monocyte activation in patients with critical limb ischemia

2010-09-01

Background: Patients with critical limb ischemia (CLI) have a high rate of adverse cardiovascular events, particularly when undergoing surgery. We sought to determine the effect of surgery and vascular disease on platelet and monocyte activation in vivo in patients with CLI.Methods: An observational, cross-sectional study was performed at a tertiary referral hospital in the southeast of Scotland. Platelet and monocyte activation were measured in whole blood in patients with CLI scheduled for infrainguinal bypass and compared with matched healthy controls, patients with chronic intermittent claudication, patients with acute myocardial infarction, and those undergoing arthroplasty (n = 30 per group). Platelet and monocyte activation were quantified using flow cytometric assessment of platelet-monocyte aggregation, platelet P-selectin expression, platelet-derived microparticles, and monocyte CD40 and CD11b expression.Results: Compared with those with intermittent claudication, subjects with CLI had increased platelet-monocyte aggregates (41.7% ± 12.2% vs 32.6% ± 8.5%, respectively), platelet microparticles (178.7 ± 106.9 vs 116.9 ± 53.4), and monocyte CD40 expression (70.0% ± 12.2% vs 52.4% ± 15.2%; P < .001 for all). Indeed, these levels were equivalent (P-selectin, 4.4% ± 2.0% vs 4.9% ± 2.2%; P > .05) or higher (platelet-monocyte aggregation, 41.7% ± 12.2% vs 33.6% ± 7.0%; P < .05; platelet microparticles, 178.7 ± 106.9 vs 114.4 ± 55.0/μL; P < .05) than in patients with acute myocardial infarction. All platelet and monocyte activation markers remained elevated throughout the perioperative period in patients with CLI (P < .01) but not those undergoing arthroplasty.Conclusions: Patients undergoing surgery for CLI have the highest level of in vivo platelet and monocyte activation, and these persist throughout the perioperative period. Additional antiplatelet therapy may be of benefit in protecting vascular patients with more severe disease during this period of increased risk.Clinical Relevance: Peripheral arterial disease is increasingly common and is associated with a significant risk of cardiovascular complications, especially at the time of surgery. Despite this, patients are poorly provided with evidence-based therapies such as antiplatelet and lipid-lowering medications. Platelets play a key role in the pathogenesis of atherothrombosis, with elevated levels of in vivo platelet activation prognostic of adverse clinical events. This study demonstrates, for the first time to our knowledge, significantly greater levels of platelet activation in patients with severe peripheral arterial disease compared with patients with acute myocardial infarction or patients undergoing other moderate- to high-risk surgical procedures. This further emphasizes the need for improved risk stratification and cardioprotection of this vulnerable group.

Oxidized LDL in human carotid plaques is related to symptomatic carotid disease and lesion instability

2010-06-23

Background: Oxidative stress is an important determinant in atherosclerosis development. Various markers of oxidative stress, such as oxidation of low-density lipoprotein (LDL), nitrosative stress, lipid peroxidation, and protein oxidation, have been implicated in the initiation and/or progression of atherosclerosis, but their association with plaque erosion and symptomatic carotid disease has not been fully defined. In addition, certain oxidative markers have been shown in various models to promote plaque remodeling through matrix metalloproteinase (MMP) activation.Objective: To perform a global investigation of various oxidative stress markers and assess for potential relationships with destabilization and symptomatic development in human carotid plaques.Methods: Thirty-six patients undergoing endarterectomy were evaluated and compared with 20 control specimens obtained at the time of autopsy. Differences between stable and unstable plaques, symptomatic and asymptomatic patients, and ≥90% and <90% stenosis were evaluated. Oxidized LDL (ox-LDL), nitrotyrosine (NT), malondialdehyde (MDA), and protein carbonyls (PCs) levels were determined in atheromatic plaques homogenates by corresponding biochemical assays. Immunohistochemical (IHC) analysis was also employed to determine the percentage and topological distribution of cells expressing NT and metalloproteinase-9 (MMP-9) in serial sections from corresponding atheromatic plaques. MMP-9 expression was further verified using Western blot analysis.Results: Ox-LDL was increased in symptomatic patients (P < .05). Also, ox-LDL and NT levels were significantly higher in unstable versus stable carotid plaques (P < .05, respectively). Furthermore, IHC serial section analysis, corroborated by statistical analysis, showed a topological and expressional correlation between NT and MMP-9 (P < .05). MDA and PCs levels, although increased in carotid plaques, did not distinguish stable from unstable carotid plaques as well as symptomatic from asymptomatic patients with various degrees of stenosis.Conclusion: All types of investigated oxidative stress markers were significantly increased in human carotid plaques, but only ox-LDL levels were associated with clinical symptoms, while peroxynitrite products and MMP-9 were specifically related to plaque instability.Clinical Relevance: Our results suggest that specific oxidative factors should be taken into consideration as additional future potential markers that could be used to assist in prevention and therapeutic decision.

Anatomical variations of the femoral vein

Jean-François Uhl, Claude Gillot, Maxime Chahim — 2010-07-02

Background: The venous anatomy is highly variable. This is due to possible venous malformations (minor truncular forms) occurring during the late development of the embryo that produce several anatomical variations in the number and caliber of the main venous femoral trunks at the thigh level. Our aim was to study the prevalence of the different anatomical variations of the femoral vein at the thigh level.Methods: This study used 336 limbs of 118 fresh, nonembalmed cadavers. The technique included washing of the whole venous system, latex injection, anatomical dissection, and then painting of the veins.Results: The modal anatomy of the femoral vein was found in 308 of 336 limbs (88%). Truncular malformations were found in 28 of 336 limbs (12%); unitruncular configurations in 3% (axo femoral trunk [1%] and deep femoral trunk [2%]). Bitruncular configurations were found in 9% (bifidity of the femoral vein [2%], femoral vein with axio-femoral trunk [5%], and femoral vein with deep femoral trunk [2%]).Conclusion: Truncular venous malformations of the femoral vein are not rare (12%). Their knowledge is important for the investigation of the venous network, particularly the venous mapping of patients with cardiovascular disease. It is also important to recognize a bitruncular configuration to avoid potential errors for the diagnosis of deep venous thrombosis of the femoral vein, in the case of an occluded duplicated trunk.Clinical Relevance: Truncular venous malformations of the femoral vein are not rare. For the investigator, it may be clinically prudent to scan the opposite limb in the presence of venous duplication since femoral vein duplication is frequently bilateral. It should also be noted that a thrombus is more likely to be seen in one canal of a duplicated femoral vein than in the normal anatomy. Thus, a thrombus in that canal could be easily missed on ultrasound. For the surgeon, femoral vein duplication could provide the opportunity to use one of the trunks for deep vein transposition reconstruction surgery of the opposite limb.

Deglutition syncope: A manifestation of vagal hyperactivity following carotid endarterectomy

Eric D. Endean, William Cavatassi, Joseph Hansler, Ehab Sorial — 2010-06-24

A 61-year-old man with left amaurosis fugax and bilateral >80% internal carotid artery stenoses underwent a left carotid endarterectomy. On the first postoperative day, he developed hypotension, bradycardia, and chest pain with food ingestion. He was diagnosed as having deglutition syncope and was treated with oral anticholinergics. Similar symptoms occurred when he underwent a right carotid endarterectomy. Deglutition syncope is a neurally mediated situational syncope resulting from vagus nerve over-activity. This is the first report of deglutition syncope associated with carotid endarterectomy. It is important to recognize and differentiate these symptoms from other causes of postendarterectomy hemodynamic instability.

Upper extremity ischemia treated with tissue repair cells from adult bone marrow

Anthony J. Comerota, Angie Link, Judy Douville, Elmar R. Burchardt — 2010-06-24

Background: Unreconstructable critical ischemia with gangrene of the upper extremity is rarely due to atherosclerosis alone, and few treatment options exist. We describe a patient with gangrene of both hands as a result of unreconstructable atherosclerotic disease of both upper extremities who was successfully treated with tissue repair cells (TRCs) produced from the patient's bone marrow.Methods: A patient with type 1 diabetes was referred with bilateral upper extremity digital gangrene due to unreconstructable forearm and hand atherosclerosis. He was evaluated for therapeutic angiogenesis using TRCs.Results: Following the intramuscular injection of TRCs produced from autologous bone marrow stem cells, the patient demonstrated improved arterial perfusion and a durable clinical response with healing of all amputation sites and cessation of pain.Conclusions: The production of TRCs results in the expansion of stem and early progenitor cells, including CD90+ mesenchymal cells and endothelial progenitor cells. This is the first reported case of end-stage upper extremity ischemia treated with TRCs harvested from adult bone marrow.

Use of a surgeon-modified branched thoracic endograft to preserve an aortorenal bypass during treatment of an intercostal patch aneurysm

Jeffrey Jim, Luis A. Sanchez, Brian G. Rubin — 2010-06-16

A 72-year-old man presented with thoracic pain. Nine years earlier, a descending aortic dissection with aneurysmal degeneration had been treated by thoracoabdominal aortic graft placement with reimplantation of a visceral patch and an intercostal patch. A separate left aortorenal bypass had also been performed with the bypass originating from the thoracic portion of the graft. He now presents with a 7.2-cm intercostal patch aneurysm in the aortic segment containing the origin of the patent aortorenal bypass. We present the use of a surgeon-modified branched thoracic endograft to salvage an aortorenal bypass originating in a thoracic aneurysm after previous open thoracoabdominal aortic aneurysm repair.

Limb salvage after delayed diagnosis for blunt traumatic infrapopliteal occlusion

2010-06-07

Infrapopliteal occlusion is uncommon after blunt trauma, and limb salvage after delayed diagnosis is even rarer. We present the case of a 56-year-old man who had complex lower leg orthopedic fractures along with a reportedly normal pulse examination with an 11-day diagnostic delay of limb-threatening ischemia requiring distal revascularization. This case illustrates an incidence of delayed infrapopliteal three-vessel occlusion with successful revascularization and subsequent endovascular management to maintain patency. We describe the workup and treatment of delayed infrapopliteal occlusion and a review of the current literature on this topic.

Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome

Olivier Hartung, Amine Azghari, Pierre Barthelemy, Mourad Boufi, Yves S. Alimi — 2010-06-24

Reimplantation of the left renal vein into the infrarenal inferior vena cava is the standard surgical procedure for nutcracker syndrome. A 40-year-old woman with a solitary left kidney suffered from left lumbar pain and hematuria. Imaging techniques found a large kidney with nutcracker syndrome. A totally laparoscopic transposition of the left renal vein was performed. Twelve months later, the patient is improved and has no more hematuria. Duplex scan showed no residual stenosis. Laparoscopic transposition of the left renal vein into the inferior vena cava is feasible with short length of stay and good short-term result.

Early side effects after embolization of a carotid body tumor using Onyx

2010-07-23

The case of a 20-year-old woman with a carotid body tumor of Shamblin class III is reported. Ten hours after preoperative direct intralesional embolization with 20 mL Onyx (ethylene-vinyl alcohol copolymer; Micro Therapeutics, Irvine, Calif), the patient showed symptoms of Horner syndrome and deficits of the hypoglossal and glossopharyngeal nerves. Intraoperative examination 12 hours after Onyx embolization revealed a massive swelling of the hypoglossal and glossopharyngeal nerves. The patient's tongue motility and glossopharyngeal function improved after surgery, but Horner syndrome was still present. Owing to the delayed occurrence of these adverse effects, the optimal time of surgical intervention after Onyx embolization should be discussed and perhaps expedited.

A rare case of familial carotid body tumor in a patient with bilateral fibromuscular dysplasia

2010-07-12

Carotid body tumors (CBTs) are neuroendocrine tumors that arise due to mutations of respiratory cycle enzymes. Fibromuscular dysplasia (FMD) is a disease that causes narrowing of medium-sized arteries. There is no documented link between CBT and FMD. In this article, we report a case of a patient with bilateral carotid FMD and familial CBT, including one in an identical twin who underwent successful surgical excision of the CBT. We describe specific considerations in the management of CBT in patients with concomitant carotid FMD. Also, we review the literature about the genetics of familial CBT and its possible relationship to the etiology of FMD.

Emergency endovascular treatment of early spontaneous nonaneurysmal popliteal artery rupture in a patient with Salmonella bacteremia

2010-07-12

Rupture of a nonaneurysmal popliteal artery and subsequent pseudoaneurysm formation is an exceedingly rare event after bacteremia caused by Salmonella spp. Only a few cases have been reported in the literature. Moreover, spontaneous popliteal artery rupture resulting from this pathology, to our knowledge, has not been reported. We describe an early spontaneous rupture of the popliteal artery complicated by acute compartment syndrome in a 67-year-old man who had recently experienced fever, chills, and diarrheal syndrome and had sustained episodes of bacteremia infection, with isolation of S enteritidis. Immediate endovascular sealing of the bleeding site was achieved with a covered stent, and his recovery was uneventful. The long-term durability of endovascular repair in this type of pathology remains to be determined, however.

Collateral pathways visualization of the innominate vein

Efrem Civilini, Germano Melissano, Luca Bertoglio, Roberto Chiesa — 2010-01-04

An asymptomatic woman underwent an angio-computed tomography (CT) scan to evaluate a thoracic aneurysm. As a collateral finding, an extrinsic compression of the innominate vein was observed. This is an uncommon condition that can be incidentally discovered with contrastographic examinations in the presence of a diminished space between the sternum and arch vessels.

Juxtarenal aortic aneurysm repair

2010-04-12

Objectives: Juxtarenal aortic aneurysms (JAA) account for approximately 15% of abdominal aortic aneurysms. Despite advances in endovascular aneurysm repair, open repair requiring suprarenal aortic cross-clamping is still the treatment of choice for JAA. We performed a systematic review of the literature to determine perioperative mortality and postoperative renal dysfunction after open repair for non-ruptured JAA.Methods: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting non-ruptured JAA repair published between January 1966 and December 2008. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included studies, and performed the data extraction. Study heterogeneity was assessed using forest plots and by calculating the between-study variance. Outcomes were perioperative mortality, postoperative renal dysfunction, and new onset of dialysis. Summary estimates with 95% confidence interval (95% CI) were calculated using a random effects model based on the binomial distribution.Results: Twenty-one non-randomized cohort studies from 1986 to 2008, reporting on 1256 patients, were included. Heterogeneity between the studies was low. The mean perioperative mortality was 2.9% (95% CI, 1.8 to 4.6). The mean incidence of new onset of dialysis was 3.3% (95% CI, 2.4 to 4.5). Incidence of postoperative renal dysfunction could be derived from 13 studies and ranged from 0% to 39% (median, 18%). In seven studies, cold renal perfusion during suprarenal clamping was performed in order to preserve renal function; however, based upon the included data, definitive conclusions regarding its efficacy could not be drawn.Conclusions: Open repair of non-ruptured JAA using suprarenal cross-clamping can be performed with acceptable perioperative mortality; however, postoperative deterioration of renal function is a common complication. Preservation of renal function after JAA repair requires further investigation.

Analysis of large databases in vascular surgery

Louis L. Nguyen, Neal R. Barshes — 2010-07-02

Large databases can be a rich source of clinical and administrative information on broad populations. These datasets are characterized by demographic and clinical data for over 1000 patients from multiple institutions. Since they are often collected and funded for other purposes, their use for secondary analysis increases their utility at relatively low costs. Advantages of large databases as a source include the very large numbers of available patients and their related medical information. Disadvantages include lack of detailed clinical information and absence of causal descriptions. Researchers working with large databases should also be mindful of data structure design and inherent limitations to large databases, such as treatment bias and systemic sampling errors. Withstanding these limitations, several important studies have been published in vascular care using large databases. They represent timely, “real-world” analyses of questions that may be too difficult or costly to address using prospective randomized methods. Large databases will be an increasingly important analytical resource as we focus on improving national health care efficacy in the setting of limited resources.

A vascular disease educational program in the preclinical years of medical school increases student interest in vascular disease

2010-08-05

Background: New training paradigms in vascular surgery necessitate medical student interest in vascular disease. We examined the effects of incorporation of a vascular disease educational program during the second year of the medical school curriculum on student acquisition of knowledge and interest in the treatment of vascular disease.Methods: We developed and administered a new educational program on vascular disease and delivered the program to all second-year medical students. The new program encompassed 9 didactic hours, including 7 traditional lecture hours and 2 hours of problem-based learning. After completing the program, students were surveyed regarding vascular disease-specific knowledge, interest in treating vascular disease, and career choices. Third-year students who were not exposed to the program were surveyed as a control group. We recorded the voluntary student enrollment in the vascular and endovascular surgery rotation during the following academic year. Voluntary enrollment of the students exposed to the vascular disease education program was compared with enrollment for the previous 8 years.Results: Before the introduction of the new educational program, 946 total lecture hours were delivered to first- and second-year medical students, comprising 490 hours (52%) given by nonsurgeon physicians, 445 (47%) by nonphysicians, and 11 (1%) by surgeons. Survey response rate was 93% (112 of 121) for second-year students and 95% (39 of 41) for third-year students. After the vascular disease program, second-year students answered 7.1 ± 1.4 of 9 vascular disease questions correctly, whereas unexposed third-year students answered 7.2 ± 1.7 questions correctly (P = .96). Most second-year medical students described a “somewhat” or “much greater” interest in the medical (63%), procedural (59%), and overall (63%) management of vascular disease after exposure to the program. Most also had a “somewhat” or “much greater” interest in a vascular medicine (64%) or vascular and endovascular surgery (60%) rotation. Enrollment in the vascular surgery third-year clerkship increased significantly to a mean of 3.0 students/month from 1.16 students/month in the prior year (P = .0032, postintervention year vs 8 prior years).Conclusion: A vascular disease educational program administered to second-year medical students increases interest in vascular disease and interest in further training. The increased interest translates to greater student enrollment in the vascular surgery clerkship in the subsequent academic year.

Discussion

2010-08-05

Dr Eric D. Endean (Lexington, Ky). I would like to thank Dr Godshall for sending me a copy of their manuscript in advance of the meeting. For a number of years, there has been concern raised regarding the interest in vascular surgery as a career choice of medical students and residents. Indeed, as borne out by the match, the pool of applicants for our programs is limited, and a significant proportion of programs go unmatched. One solution has been to propose and create Vascular Surgery Integrated programs, of which there are currently 21 approved programs. I have wondered how these programs will attract students. In my own experience, vascular surgery is not a specialty that has immediate name recognition. For example, when telling someone that I practice vascular surgery, the typical response I receive is “Oh, you do varicose veins.” Looking back at my own career path, even though I rotated on a vascular surgery service as a third-year medical student, I was unable to commit to a career in vascular surgery until midway through my residency. I have also found that the majority of candidates applying for general surgery are considering fellowship training but are unwilling to commit to a specific area as a medical student.

Agitation thrombolysis for fresh iatrogenic IVC thrombosis in patients with Budd-Chiari syndrome

Peng-Xu Ding, Yong-Dong Li, Xin-Wei Han, Gang Wu — 2010-05-17

Three patients with Budd-Chiari syndrome (BCS) and fresh inferior vena cava (IVC) thrombosis were treated by agitation thrombolysis as a mechanical thrombectomy procedure and followed up by duplex ultrasonography. Agitation thrombolysis was technically and clinically successful in all patients. Inferior vena cavagrams after the procedure showed complete resolution of the iatrogenic, fresh IVC thrombi without occurrence of pulmonary embolism. Duplex ultrasonography follow-ups after 12, 24, and 28 months, respectively, confirmed complete patency of the IVC without rethrombosis and reobstruction. The results indicate that agitation thrombolysis may be a safe and feasible approach for BCS patients with iatrogenic, fresh IVC thrombosis.

Novel technique for endovascular salvage of a folded aortic endograft

Joseph J. Ricotta, Rafael D. Malgor — 2010-06-07

Endovascular aneurysm repair (EVAR) has been established as a safe and effective treatment modality for infrarenal abdominal aortic aneurysms. Endograft migration resulting in a proximal type I endoleak can be one of the most difficult challenges following EVAR. Often, this precludes endovascular treatment and necessitates conversion to open surgical repair. We report a case of a high-risk patient who presented with impending abdominal aortic aneurysm rupture as a result of endograft migration following EVAR performed 5 years prior. The endograft had folded over on itself within the aneurysm sac and was successfully repaired using a total endovascular approach.

The influence of Dominique Jean Larrey on the art and science of amputations

David R. Welling, David G. Burris, Norman M. Rich — 2010-06-23

“Un grand nombre de blessures, faites par l'artillerie, ont exigé l'amputation d'un ou de deux members. J'en ai pratiqué, dans les premières vingt-quatre heures, environ deux cents…”“A great number of wounds, created by artillery, required the amputation of one or two limbs. I accomplished, in the first twenty-four hours, around two hundred…”Dominique Jean Larrey, writing of the Battle of Borodino

Arm vein conduit vs prosthetic graft in infrainguinal revascularization for critical leg ischemia

Sean P. Roddy — 2010-09-01

This article presents one institution's outcomes with infrainguinal arterial reconstruction using arm vein and prosthetic conduits. Coding for lower extremity arterial revascularization is based on inflow artery, outflow artery, and conduit. There is no difference between the above-knee and the below-knee popliteal artery for billing purposes. Additionally, “femoral” in the CPT descriptions denotes either the common, superficial, or deep femoral artery. Conduit options include “vein”, “in-situ saphenous vein”, and “other than vein”. “Vein” comprises harvest and preparation of saphenous vein from the same or opposite leg, whether it is reversed or left in an orthograde configuration. No extra coding is available for rendering valves incompetent. “Other than vein” is appropriate when prosthetic material (eg, Dacron or expanded polytetrafluoroethylene), umbilical vein, cryopreserved vein, or an excised artery (eg, radial or hypogastric) is utilized. Based on the introductory wording in the subsection entitled “Arteries and Veins” within the “Cardiovascular System” segment of the CPT manual, all manipulation for the purpose of “establishing both inflow and outflow by whatever procedures necessary” is bundled. Therefore, endarterectomy or patch angioplasty at the inflow/outflow vessel anastomosis is not separately reportable. National Correct Coding Initiative (NCCI) edit pairs have been created to that end.

A randomized, controlled trial of endovenous thermal ablation using the 810-nm wavelength laser and the ClosurePLUS radiofrequency ablation methods for superficial venous insufficiency of the great saphenous vein

Sean P. Roddy — 2010-09-01

This article evaluates patients with superficial venous insufficiency due to greater saphenous vein incompetence treated with endovenous ablation. Open surgical venous intervention on saphenous vein pathology has been discussed in a previous article. Endovenous ablation therapy CPT coding was introduced in 2005. The two treatment technologies both involve catheter-based venous access under ultrasound guidance but impart thermal energy using different modalities to the vein wall: namely, radiofrequency or laser. Therefore, there are two sets of code descriptions available. Radiofrequency uses CPT code 36475, which states “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated”, while laser relies upon CPT code 36478, which denotes “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated”. The majority of cases use this technology on the greater saphenous vein. However, the lateral accessory saphenous vein and the lesser saphenous vein are alternatives based on clinical indication. If two or more of these veins are ablated in the same setting, add-on codes have been created to describe the additional work. CPT code 36476 depicts “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)”, while CPT code 36479 states “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)”. In CPT wording, “second and subsequent” means that the code is reported only once per session regardless of the number of veins treated. For example, if two veins are treated with radiofrequency in the same leg, CPT codes 36475 and 36476 would be submitted to the insurance carrier. If three or more veins are treated in the same leg and in the same setting, the billing is identical to the “two vein scenario” above (CPT code 36476 is not reported more than once or with a unit value greater than one). However, bilateral intervention requires the −50 modifier (bilateral procedure) and is applicable to all four vein ablation codes listed above.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

P. Puech-Leão, C.R. Bregalda Neves, E. Simão da Silva — 2010-09-01

Conclusion: Carotid artery angioplasty and stenting can be successfully performed in patients with internal carotid artery pseudo-occlusion or string sign. Summary: This report focuses on carotid angioplasty and stenting in a series of patients in whom the internal carotid artery (ICA) was thought occluded by conventional ultrasound but who actually had string signs. The authors treated 16 patients. Contrast computed tomography (CT) showed a patent distal ICA in 14 of the 16 patients treated. Contrast-enhanced ultrasound imaging also showed patent distal ICAs in 13 cases.

A Large-Scale Study of the Upper Arm Basilic Transposition for Hemodialysis

C. Glass, J. Porter, M. Singh — 2010-09-01

Conclusion: Basilic vein transposition fistulas have excellent maturation rates and good functional patency at 1 year. Major limitations to long-term durability are the need for frequent revisions and central venous stenosis.

A Comparison of Clopidogrel Responsiveness in Patients With versus Without Chronic Renal Failure

S.H. Park, W. Kim, C.S. Park — 2010-09-01

Conclusion: Patients with chronic renal failure have decreased responsiveness to clopidogrel compared with patients without chronic renal failure. This decreased responsiveness is not corrected by an increase in the clopidogrel dosage.

Infectious Burden and Carotid Plaque Thickness: The Northern Manhattan Study

M.S.V. Elkind, J.M. Luna, Y.P. Moon — 2010-09-01

Conclusion: Carotid plaque thickness in a multiethnic cohort is associated with a quantitative weighted index of infectious burden derived from the magnitude of association of individual infections with stroke.

Limb-Shaking Transient Ischaemic Attacks in Patients With Internal Carotid Artery Occlusion: A Case-Control Study

S. Persoon, L.J. Kappelle, C.J.M. Klijn — 2010-09-01

Conclusion: Transient ischemic attacks (TIAs) marked by limb-shaking are associated with high-grade carotid stenosis or internal carotid artery occlusion and can be recognized by short duration and precipitation by rising or exercise. They are also accompanied frequently by paresis and indicate an impaired hemodynamic state of the brain.

New Ischemic Brain Lesions on MRI after Stenting or Endarterectomy for Symptomatic Carotid Stenosis: A Sub-Study of the International Carotid Stenting Study (ICSS)

L.H. Bonati, L.M. Jongen, S. Haller, ICSS-MRI study group — 2010-09-01

Conclusion: In a substudy of patients randomized in the International Carotid Stenting Study (ICSS) comparing carotid artery stenting with carotid endarterectomy for symptomatic carotid stenosis, patients randomized to the stenting group had three times more ischemic lesions found by post-treatment magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI) than patients randomized to the endarterectomy group. Cerebral protection devices did not seem to be effective in preventing ischemic DWI lesions after stenting.

Patient Outcomes after Acute Pulmonary Embolism: A Pooled Survival Analysis of Different Adverse Events

F.A. Klok, W. Zondag, K.W. van Kralingen — 2010-09-01

Conclusion: Within 4 years of acute pulmonary embolism (PE), half the patients will have an additional serious adverse clinical event. Summary: Most articles on acute PE focus on incidence and case fatality rates. There are little data on the long-term fate of the patients. This report, however, does provide a more long-term perspective of the fate of patients with PE. We know that death related to PE occurs in approximately 2% to 6% of patients with a hemodynamically stable PE and in >30% of patients with PE presenting with shock or hemodynamic instability (Chest 2002;121:877-905; Arch Intern Med 2004;164:92-96). About 25% of patients do not survive the first year after the diagnosis of PE, with most deaths relating to cancer or chronic heart disease rather than to PE itself (N Engl J Med 1992; 326:1240-1245). We also know that patients with PE are at risk for recurrent PE, chronic thromboembolic pulmonary hypertension, arterial cardiovascular events, and a new diagnosis of cancer (N Engl J Med 1998;338:1169-73; AMA 2005;293:2352-61). The goal of this study was to assess long-term risk for adverse events after PE.

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

T.G. Brott, R.W. Hobson, G. Howard, CREST Investigators — 2010-09-01

Conclusion: In patients with symptomatic or asymptomatic carotid stenosis, a composite outcome of stroke, myocardial infarction, or death does not differ between patients undergoing endarterectomy or those undergoing carotid artery stenting. During the periprocedural period, there is a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy.

Synchronous Cardiac and Carotid Revascularisation: The Devil is in the Detail

A.R. Naylor — 2010-09-01

Background: Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure.

An Update of the Role of Endovascular Repair in Blunt Carotid Artery Trauma

K.G. Moulakakis, S. Mylonas, E. Avgerinos, T. Kotsis, C.D. Liapis — 2010-09-01

Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40–80% and mortality rate of 25–60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

Determinants of Radiation Exposure during EVAR

S.A. Badger, C. Jones, C.S. Boyd, C.V. Soong — 2010-09-01

Objectives: Endovascular aneurysm repair (EVAR) is an established method of aortic aneurysm repair, in favourable anatomical configurations. It does however expose patients to radiation. The study aim was to determine if the aneurysm neck morphology influenced radiation exposure.

Pulsatile Distension of the Proximal Aneurysm Neck is Larger in Patients with Stent Graft Migration

J.W. van Keulen, F.L. Moll, G.K. Barwegen, E.P.A. Vonken, J.A. van Herwaarden — 2010-09-01

Purpose: The proximal abdominal aortic aneurysm (AAA) neck expands significantly during the cardiac cycle, both before and after endovascular aneurysm repair (EVAR). Clinical consequences of this pulsatility were anticipated but have never been reported. This study investigated whether there is a relation between stent graft migration and preoperatively measured pulsatility of the proximal aneurysm neck.

A Computational Study of the Magnitude and Direction of Migration Forces in Patient-specific Abdominal Aortic Aneurysm Stent-Grafts

D.S. Molony, E.G. Kavanagh, P. Madhavan, M.T. Walsh, T.M. McGloughlin — 2010-09-01

Objectives: Endovascular aneurysm repair for abdominal aortic aneurysm (AAA) is now a widely adopted treatment. Several complications remain to be fully resolved and perhaps the most significant of these is graft migration. Haemodynamic drag forces are believed to be partly responsible for migration of the device. The objective of this work was to investigate the drag forces in patient-specific AAA stent-grafts.

Accuracy of FDG-PET–CT in the Diagnostic Work-up of Vascular Prosthetic Graft Infection

2010-09-01

Objectives: To investigate the diagnostic accuracy of fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) compared with computed tomography (CT) scanning and added value of fused FDG-PET–CT in diagnosing vascular prosthetic graft infection.

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery

2010-09-01

Objectives: Smoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers.

Clopidogrel Is Not Associated With Major Bleeding Complications During Peripheral Arterial Surgery

2010-09-01

Persistent variation in practice surrounds preoperative clopidogrel (Plavix) management at the time of vascular surgery. Although some surgeons preferentially discontinue clopidogrel, citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery.

Standardized Angioplasty and Stenting Techniques for SFA-Popliteal TASC C and D Lesions Improve Outcomes: A Prospective Evaluation

2010-09-01

This study evaluated whether standardization of superficial femoral-above knee popliteal artery (SFA-AK-PA) percutaneous angioplasty and stenting (PTAS) improves outcomes when treating TASC C and D lesions

Lower Extremity Revascularization (LER) in Young Patients: Have Endovascular Options Impacted Practice and Outcomes?

2010-09-01

This study assessed outcomes and utilization of revascularization options in young patients with premature vascular disease. A retrospective comparison of LER outcomes from 2000-2008 was performed between consecutive patients aged <50 years (group A) at the time of revascularization and control groups B (51-60 years) and C (>60 years) of selected patients with comparable indications and procedures. Kaplan-Meier curves and logistic regression analyses were applied to patency, limb salvage, and survival on limb level or patient level, as indicated.

Comparison of Ultrasound Accelerated Thrombolysis Versus Simple Infusion Catheter Directed Thrombolysis for Acute Arterial Thrombosis

2010-09-01

Catheter-directed intra-arterial thrombolysis for acute peripheral arterial ischemia has become a standard practice for acute arterial thrombosis. There has been significant amount of literature published as far as the choice of the thrombolytic agent and injection techniques. One technique used to accelerate thrombolysis is with the use of ultrasound imaging (EKOS). We looked at our experience to compare the outcomes with a simple side-hole infusion catheter (Unifuse) vs EKOS catheters.

Cryoplasty Offers No Advantage Over Standard Balloon Angioplasty for the Treatment of In-Stent Restenosis

2010-09-01

In-stent restenosis is the primary failure mode of endovascular treatment of occlusive disease in the femoropopliteal segment. Cryoplasty has been proposed to reduce intimal hyperplasia through induction of apoptosis. We sought to evaluate the efficacy of cryoplasty for treatment of in-stent restenosis compared with conventional balloon angioplasty (CBA).

Anatomic Patterns of Failure After Infrainguinal Percutaneous Revascularization

Mounir J. Haurani, Mark F. Conrad, Vikram Paruchuri, Richard P. Cambria — 2010-09-01

Percutaneous revascularization (PTA) of infrainguinal occlusive disease is associated with a significant recurrence rate, with a 15% to 25% reintervention rate to maintain secondary patency. Other studies have focused on clinical predictors of such failure, but little is known of the anatomy of such failures, which is the goal of this study.

Role of IVUS Versus Venograms in Assessment of Iliac-Femoral Vein Stenosis

2010-09-01

Lower extremity venous stasis disease could be related to outflow obstruction in the iliac-femoral vein segments due to stenosis or extrinsic compression. Conventional methods to assess these vein segments include transcutaneous ultrasonography and ascending venography. The transcutaneous approach has a low sensitivity, and venography can miss significant lesions as the assessment is undertaken in a single view. We assessed the role of intravenous ultrasound (IVUS) imaging in detecting the location as well as the degree of stenosis in the iliac-femoral vein segments.

Venous Ablation Can Be Performed Safely on High-Risk Patients

2010-09-01

Patients with a previous history of deep vein thrombosis (DVT) or a family history of DVT are considered at high risk for thrombotic complications (DVT) after endovenous ablation (EVA). In this study, we examine our outcomes on patients presenting for “high-risk” EVA.

Clinical Outcomes With Covered Stent Placement for Central Venous Occlusive Disease in Hemodialysis Patients

2010-09-01

The use of covered stents (CSs) has been proposed as a new treatment option for central venous occlusive disease (CVOD) in hemodialysis patients. Among its advantages include the mechanical support of bare-metal stents while providing an inert and stable intravascular matrix for endothelialization. The aim of this study is to evaluate the efficacy and durability of CSs in treating central venous stenosis while preserving hemodialysis access patency.

Placement Issues for Hemodialysis Catheters With Pre-existing Central Lines and Catheters

2010-09-01

It has been a widely accepted practice that a previously placed pacemaker was a contraindication to placing a hemodialysis catheter in the ipsilateral internal jugular vein. Fear of dislodging pacing wires, tunneling close to the battery site, or causing venous obstruction has been a concern for surgeons and interventionalists alike. We suggest that this phobia is unfounded.

Cervical Ribs—A Rare Entity but Clinically Significant

Julie A. Freischlag, Kevin Chang, Merve Gurkar, Thomas Reifsnyder, Kylie Davis — 2010-09-01

Owing to their unique presentation, we reviewed our operative experience in patients with large, clinically significant cervical ribs. This was a retrospective review of a prospectively acquired database.

Clinical Outcomes for Hostile Versus Favorable Aortic Neck Anatomy in Endovascular Aortic Aneurysm Repair Using Modular Devices

2010-09-01

This study analyzed the clinical implications of various clinical features of proximal aortic neck anatomy in EVAR using modular devices. A total of 258 EVAR patients were divided into favorable (FNA) or hostile neck anatomy (HNA). HNA was defined as having one or more of the following features: length of <10 mm, angle of >60°, diameter of >28 mm, ≥50% circumferential thrombus, ≥50% calcified neck, and reverse taper.

Long-term Survival After Endovascular and Open Repair of Ruptured Abdominal Aortic Aneurysms

2010-09-01

This study compared the late outcomes in patients who survived 30 days after endovascular aneurysm repair (EVAR) and open repair (OR) for ruptured abdominal aortic aneurysms (RAAA).

Total Sac Retraction After Endovascular Aneurysm Repair: 4 Years' Follow-Up, Correlation to Treatment Success and Predictive Factors

Rabih Houbballah, Marek Majewski, Jean-Pierre Becquemin — 2010-09-01

The principal aim of this study was to demonstrate that the total sac retraction (TSR) was a predictive marker of durable success after endovascular aneurysm repair (EVAR). If verified, surveillance of patients with TSR may become unnecessary. We also tested patients and aneurysm-related factors that may predict the occurrence of TSR.

Synchronous and Metachronous Thoracic Aneurysms (TAA) in Patients With Abdominal Aortic Aneurysms (AAA)

2010-09-01

Although the association of TAA with AAA is known, the exact incidence has not been described. Our goal was to quantify the incidence of TAA in patients with an AAA and assess predictive factors for its diagnosis.

Type I Endoleak: Impact of Graft Selection and Anatomic Factors

2010-09-01

This study aimed to assess the impact of anatomic and aortic endovascular graft characteristics on the occurrence of type 1 endoleak after endovascular abdominal aortic aneurysm repair (EVAR).

Outcome of Elective Endovascular Abdominal Aortic Aneurysm Repair in Nonagenarians

2010-09-01

Compared with open repair of abdominal aortic aneurysms (AAA), endovascular repair (EVAR) is associated with decreased perioperative morbidity and mortality in a standard patient population. This study sought to determine if the advantage of EVAR extends to patients aged ≥90 years.

Outcome of Carotid Artery Interventions Among Female Patients in the United States, 2004-2005

2010-09-01

The benefit of carotid endarterectomy (CEA) in women has been questioned, particularly in asymptomatic cases, and an increased in perioperative stroke in women after CEA has been noted. The outcome of carotid artery angioplasty and stenting (CAS) has not been extensively evaluated in women. Our objective was to examine the national outcome of CEA and CAS in female patients.

Impact of Elevated Fasting Blood Glucose on the Outcomes of Carotid Artery Stenting

2010-09-01

Carotid artery stenting (CAS) for high-risk individuals is accepted practice. An elevated fasting blood sugar (FBS) is often associated with poor procedural outcomes after other percutaneous procedures. The clinical outcomes of CAS for patients with elevated FBS is not well defined.

Early Results of Stents Placed at the Origin of the Great Vessels: Does Indication Influence Outcome

2010-09-01

Indications for balloon-expandable stent (BES) placement in the great vessels include occlusive atherosclerotic disease as well as vessel origin protection when thoracic endografts are placed with overlap of the vessel origin. We compared early outcomes of in-stent restenosis in these two groups of patients: those being treated for occlusive disease and those treated as an adjunct to TEVAR.

Short Access Surgery for Carotid Artery Intervention Facilitated by a Modified Guiding Sheath

Paul B. Haser, Daniel I. Fremed, Alan M. Graham — 2010-09-01

Carotid access for stenting can be problematic due to anatomic variations and/or aortic arch pathology. For rare cases best treated by direct puncture of the common carotid artery (CCA), there is added difficulty due to ergonomic and angulation issues, even with surgical exposure. A newly designed access sheath, the H2H Guiding Sheath, facilitates short access surgery (SAS) and reduces arterial damage.

Correlation of Carotid Stump Pressure During Carotid Endarterectomy and the Contralateral Carotid/Cerebral Collateral Flow: Results from a Randomized Trial

2010-09-01

The optimal method for predicting when carotid shunting during carotid endarterectomy (CEA) is unnecessary is controversial. This study analyzed the correlation of carotid stump pressure (CSP) and the status of contralateral carotid/cerebral collaterals and determined whether preoperative duplex ultrasound (DUS)/cerebral angiography (angio) can predict when CEA can be done without shunting.

Changes in Patient Selection in Lower Extremity Bypass in New England: Lower Risk, Better Outcomes

2010-09-01

Surgeons, payers, and providers have recently placed increasing emphasis on risk assessment and outcomes reporting in vascular surgery. Accordingly, we studied the change in the risk profiles of patients undergoing lower extremity bypass surgery (LEB) in New England.

Outcomes Following Endovascular Intervention for Chronic Critical Limb Ischemia by Rutherford Classification

Maciej L. Dryjski, Monica O'Brien-Irr, Linda Harris, Hasan Dosluoglu — 2010-09-01

This study evaluated outcomes after endovascular intervention (EVI) for chronic critical limb ischemia (CLI) by Rutherford class (RC4: rest pain; RC5: tissue loss). The medical records of all EVI performed for RC 4-5 by vascular surgeons at a single institution during a 3-year period were reviewed for the following outcomes. Sustained clinical success (SCS)—Rutherford Improvement Score (RIS): 2+, without target extremity revascularization (TER). In RC5 patients, patency until healing; healing ≤4 months without recurrence or new ulceration. Secondary sustained clinical success (SSCS)—RIS: 2+ with TER. In RC5 patients; patency until healing; healing at any time during follow-up, without recurrent or new ulceration. Data were analyzed using SPSS. Significance was established at the 0.05 level.

Lesion and Device Characteristics That Predict Distal Embolization During Percutaneous Lower Extremity Interventions

2010-09-01

Distal embolization (DE) during percutaneous lower extremity revascularization (LER) may cause severe clinical sequelae. To better define DE, we investigated which lesion characteristics and treatment modalities increase the risk for embolization.

Simultaneous TEVAR and EVAR is Feasible with Minimal Morbidity and Mortality

2010-09-01

To determine the results of simultaneous TEVAR and EVAR. Records were retrospectively reviewed. Seven patients (5 men; mean age, 73 years) underwent simultaneous TEVAR and EVAR between 1999-2009 at a single center. All patients had concomitant thoracic and abdominal aneurysms. The average diameters of the thoracic and abdominal aneurysms were 6.6 and 6.3 cm, respectively. Three patients were treated emergently, and the remainder had urgent indications for simultaneous repair. All patients had significant comorbidities (HTN, CAD, CHF, smoking, COPD).

Root Cause of Fortron Suprarenal Stent Fractures

Jonathon A. Rubin, Zhonghua Li, Bruce J. Brener — 2010-09-01

Clinical experience has revealed that most nitinol AAA stent grafts suffer from suprarenal stent fracture that could potentially result in caudal prosthesis migration and/or type I endoleak. There is limited understanding of the mechanism of suprarenal stent fracture. The aim of this study was to investigate the root cause of fracture based on theoretical analysis, in vitro testing, in vivo image observation, and clinical follow-up.

Evaluating Preventable Adverse Events: Patient Safety After Elective Lower Extremity Procedures

2010-09-01

Improving patient safety has become a national priority. Patient Safety Indicators (PSIs) are validated tools to identify potentially preventable adverse events. No studies exist evaluating lower extremity (LE) vascular procedures and the occurrence of PSIs.

Patients with Hypertension Have a High Incidence of Peripheral Arterial Disease Correlating With the Severity of Their Hypertension

David Reznick, John Blebea, John Wang, Michael Smith, Eric Yasinow — 2010-09-01

Although it is well established that patients with peripheral arterial disease (PAD) have a higher incidence of hypertension (HTN), studies have not examined if patients with HTN are at higher risk for PAD. We prospectively investigated the incidence of PAD as a function of the severity of HTN.

Prevalence and Effects of BMI on Hospital Course, 30-Day Mortality, and Morbidity in Patients Undergoing Endovascular Procedures

2010-09-01

Obesity is common in patients presenting with vascular diseases and has been associated with increased perioperative complications with open surgical procedures, but the effect of body mass index (BMI) on endovascular procedures is uncertain. This study was to determine the effect of BMI on hospital course and 30-day mortality and morbidity on patients undergoing endovascular surgical procedures.

Modeling the Long-Term Effects of Early Endovascular Intervention for Uncomplicated Type-B Dissection: The Effects of Late Aneurysm Formation

2010-09-01

Recent data show no differences in survival to 2 years when chronic (2 to 52 weeks from symptom onset) uncomplicated type B aortic dissection is treated medically or with thoracic endovascular repair (TEVR). The high rate of late aneurysmal degeneration, however, coupled with the high mortality and paralysis rate of this entity, is critical to include in any analysis of the relative effectiveness of these two treatments.

Should Endovascular Aneurysm Repair Be Offered to Patients with Short Infrarenal Necks?

2010-09-01

One of the most important determinants for successful endovascular repair of abdominal aortic aneurysms (EVAR) is adequate infrarenal aortic neck length. We reviewed our experience with EVAR in patients with short (<15 m) infrarenal necks focusing on the incidence, treatment, and midterm outcome of proximal attachment site endoleaks.

Contemporary Management of Ruptured Abdominal Aortic Aneurysms in the Medicare Population

2010-09-01

Endovascular repair of intact abdominal aortic aneurysms (EVAR) has been shown to decrease morbidity and resource utilization compared with open repair (open). However, the utility of EVAR for the repair of ruptured abdominal aortic aneurysms (RAAA) remains unknown. This study used the Medicare database to evaluate trends in RAAA volume and compared outcomes of open and EVAR repair of RAAA in contemporary practice.

Should the Vascular Surgeon Continue Performing Temporal Artery Biopsies?

2010-09-01

Giant-cell arteritis is one of the most common vasculitic disorders that a vascular surgeon encounters during daily practice. According to American College of Rheumatology guidelines, the diagnosis can be established on clinical findings without the need of a pathologic specimen. We examined the current experience of vascular surgery service performing temporal artery biopsies.

Successful Robot-Assisted Pulmonary Artery Stenting of High-Grade Anastomotic Artery Stenosis Following Single Lung Transplantation

2010-09-01

Stenosis at the pulmonary artery (PA) anastomosis after lung transplantation is a rare complication that has poor prognosis even after surgical correction. We present the first case of PA anastomotic stenosis that was successfully treated with the assistance of a remote robotic catheter navigation system (Hansen Sensei system) because of failure of conventional interventional techniques.

Endovascular Repair of a Collapsed Abdominal Aortic Endograft due to Bird-Beaking

2010-09-01

Aortic endograft collapse is a rare complication described predominately in thoracic aortic endografts. Factors predisposing to graft collapse include excessive oversizing, tight aortic arch diameter, and poor wall apposition of the graft resulting in a “bird's beak” phenomenon. Here we report an interesting case of a collapsed abdominal aortic endograft repaired using endovascular techniques.

Proximal Aortic Aneurysm and Pseudoaneurysm Formation Following Endovascular Thoracic Aortic Aneurysm Repair

Dustin Fanciullo, Karl A. Illig, Jason Kim, David Gillespie, Michael J. Singh — 2010-09-01

Thoracic endovascular aortic repair (TEVAR) of descending thoracic aortic aneurysms has been frequently performed since the release of commercially available endografts. TEVAR is an attractive option for the treatment of complex aortic disease and maintains a relatively low reintervention rate. This case series describes three patients who developed proximal fixation aneurysms that were discovered with meticulous postoperative endograft surveillance and were successfully repaired with a secondary endovascular intervention.

Management of Inadvertent Iatrogenic Subclavian Artery Injury With an Extravascular Bio-Inert Sealant

2010-09-01

Inadvertent arterial puncture is a complication of placement of central catheters; this can lead to arterial occlusion, embolism, pseudoaneurysm formation, vessel laceration, or dissection. To prevent the occurrence of these complications, the central catheter has to be removed, but direct pressure is not an adequate option in the subclavian artery. The management of this complication does not have a standard accepted treatment.

Kissing Iliac Artery Stents For Hypogastric Artery Occlusion During EVAR

Patrick A. Stone — 2010-09-01

During an endovascular aneurysm repair (EVAR), dissection occurred in the bilateral common and external iliac arteries, resulting in acute bilateral hypogastric artery occlusion. Attempts were made to re-establish flow to the left internal iliac artery through a retrograde ipsilateral approach, without success. A left brachial approach was used to gain access to the left internal iliac artery. Kissing angioplasty and subsequent stent placement with two self-expanding stents was performed, raising the iliac bifurcation to the level of the stent graft in the common iliac artery to salvage the internal iliac artery. The patient postoperatively developed right lower extremity weakness and paresthesia, despite a normal ABI >0.7, which raised the question of spinal cord-related injury from pelvic malperfusion and suggested that if both stenosis were not treated, this could have resulted in significant morbidity.

Spontaneous Dissection with Rupture of the Superior Mesenteric Artery From Segmental Arterial Mediolysis: A Case Report and Review of the Literature

Michael N. Tameo, Matthew J. Dougherty, Keith D. Calligaro — 2010-09-01

Spontaneous dissection of the superior mesenteric artery (SMA) is rare. We report a case of rupture of the SMA after spontaneous dissection in a 51-year-old man who presented with acute onset of abdominal pain and hypotension. The patient was diagnosed as having segmental arterial mediolysis (SAM).

In Vivo Evaluation of a Hand-Held, Battery-Operated Therapeutic Ultrasound Device for the Noninvasive Treatment of Varicose Veins

2010-09-01

Current treatments for varicose veins and other vascular malformations are to some degree invasive and may therefore be painful and associated with complications such as infection, thrombophlebitis, and bleeding. The development of entirely noninvasive techniques has been hampered by the high cost, large size, and power requirements of candidate technologies, such as high-intensity focused ultrasound (HIFU) imaging. Our group has developed a HIFU device that is hand-held and battery-operated, and we have previously demonstrated that it is capable of venous ablation ex vivo. The purpose of this study was to determine whether it is capable of transcutaneous venous ablation in vivo.

Regulation of Membrane-Type Matrix Metalloproteinase Expression by Recanalization and Flow During Thrombus Resolution

Mohammed Chaudry, Christine Chabasse, Rajabrata Sarkar — 2010-09-01

Expression and activity of matrix metalloproteinase (MMP) enzymes is important in the process of venous thrombus resolution. Expression of the membrane-type MMP family of genes (MT-MMPs) in thrombus resolution, and the regulation of their expression by blood flow (recanalization) remain undefined. We tested the hypothesis that thrombus resolution would activate these genes and that recanalization would further regulate their expression.

Human Adult Stem Cells Restore Endothelial Migratory Dysfunction in a Hypoxic Environment

2010-09-01

Adipose-derived stem cells (ASCs) injected into the blood stream after an ischemic event promote therapeutic angiogenesis in affected tissues. It has been suggested that the stem cells exert their influence by way of a paracrine effect on native endothelial cells (ECs). Using an in vitro model, we evaluated the effect of ASC coculture on EC function in a hypoxic environment.

The Effect of Nitric Oxide and Statins on Thrombospondin-1-Induced Chemotaxis in Vascular Smooth Muscle Cells

Keri A. Seymour, Xuan Han, Benjamin Sadowitz, Kristopher G. Maier, Vivian Gahtan — 2010-09-01

Vascular smooth muscle cell (VSMC) chemotaxis is important in intimal hyperplasia (IH). Nitric oxide (NO), a diffusible molecule that decreases VSMC chemotaxis to several growth factors, is protective against IH. Thrombospondin-1 (TSP-1), a matricellular glycoprotein that induces VSMC chemotaxis, acts antagonistically to NO in VSMCs. Statins exhibit direct and pleiotropic effects on VSMCs. We showed overnight treatment with lovastatin inhibited TSP-1-induced VSMC chemotaxis by mevalonate pathway inhibition and was Ras dependent. Hypothesis: Short-term statin treatment will inhibit TSP-1-induced VSMC chemotaxis and NO donors will enhance statin inhibitory effects.

Aged Rats Have Increased Neointimal Thickening and Ephrin-B2 Expression After Carotid Angioplasty

2010-09-01

Although carotid angioplasty is associated with increased adverse events in elderly patients compared with younger patients, some animal models of carotid angioplasty have previously demonstrated only negative remodeling in aged rats compared with younger rats. Therefore, we examined the response to carotid artery angioplasty using a validated animal model of aging.

Tissue Culture Analysis of an Intact Carotid Plaque: Is Cryoplasty an Option for Carotid Intervention?

2010-09-01

Angioplasty imparts a cellular response to vascular smooth muscle cells (VSMCs) that contributes to intimal hyperplasia (IH). Previous cell culture manipulation has imputed that apoptosis follows rapid freezing, but no direct plaque sampling has confirmed this. An ex vivo carotid plaque model allows procedure-specific histologic and biologic assessment of metabolically active tissue.

Regarding “Long-term outcomes and resource utilization of endovascular versus open repair of abdominal aortic aneurysms in Ontario”

Hisato Takagi, Masafumi Matsui, Takuya Umemoto — 2010-09-01

A population-based study by Jetty et al demonstrated a significant reduction in 30-day mortality (adjusted hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.20-0.59) with endovascular repair (EVR) relative to open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) but no significant difference in 5-year mortality (adjusted HR, 0.95; 95% CI, 0.81-1.05). To determine until when the perioperative survival advantage with EVR compared with OSR is sustained, we performed a meta-analysis of randomized controlled trials (RCTs) of EVR vs OSR for AAAs.

Regarding “A closer look at meta-analyses of observational data”

Eliano Pio Navarese, Antonino Buffon, Giuseppe De Luca, Stefano De Servi — 2010-09-01

We read carefully the article by Jonker et al. entitled “Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm”. Observational studies were retrieved in the meta-analysis. When dealing with meta-analyses, in particular with meta-analyses of nonrandomized data, some key points in the building up process of the analysis must be considered.

Reply

2010-09-01

We would like to thank Navarese et al for their interest and reaction regarding our meta-analysis about the outcomes of open and endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAA). We agree that meta-analyses of non-randomized studies have considerable limitations, which we have addressed in the limitations section at the end of the article. Currently, no randomized controlled trials or large prospective studies have compared the outcomes of open and endovascular repair of rDTAA, and the optimal approach for this emergency remains unclear. Given the rarity of this condition, and its emergent nature, it will be very difficult to ever realize a randomized study investigating the outcomes of rDTAA after both treatments. In the absence of level I evidence, we decided to perform a meta-analysis of the available studies between 1995 and June 2009, in order to provide more insights into this rare but lethal disease, by reporting the overall results of open and endovascular repair of rDTAA in the literature. Despite the described limitations of such a meta-analysis, we believe that our methodology was adequate and that the article provides a concise summary of the published outcomes, which could, therefore, improve the current knowledge about the management and outcomes of rDTAA.

Regarding “Preoperative statin therapy is associated with improved outcomes and resource utilization in patients undergoing aortic aneurysm repair”

Hisato Takagi, Shin-nosuke Goto, Masafumi Matsui, Hideaki Manabe, Takuya Umemoto — 2010-09-01

McNally et al demonstrated, in their retrospective analysis of 401 patients undergoing elective abdominal aortic aneurysm repair, that postoperative mortality rate was significantly decreased in the open repair statin cohort compared with the nonstatin open repair cohort and trended to be decreased in the endovascular repair statin group. Previous meta-analyses, which combined unadjusted odds ratios (ORs) in nonrandomized studies, also suggested that preoperative statin therapy was associated with lower postoperative mortality after vascular surgery. Since these meta-analyses were conducted, however, results of a number of controlled studies have been reported to date. In the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III (DECREASE III) trial, a recent large randomized double-blind placebo-controlled trial in patients undergoing vascular surgery, perioperative statin therapy reduced not postoperative death but myocardial ischemia or the composite of death from cardiovascular causes and myocardial infarction. Combining not unadjusted but adjusted risk estimates in nonrandomized studies, we performed an updated meta-analysis of controlled studies of preoperative statin therapy for the prevention of postoperative mortality in vascular surgery.

Reply

Michael C. Stoner — 2010-09-01

We read the comments from Takagi et al with great interest. Their letter outlines an interesting and thought-provoking meta-analysis demonstrating the protective benefits of preoperative statin therapy in patients with noncoronary vascular disease. In addition to the studies cited in our manuscript, this letter cites several other important sources which add credence to our hypothesis regarding the influence of statin-class drugs on operative outcomes and resource utilization after aneurysm surgery. Takagi et al should be commended for this analysis, and we would urge the authors to consider a robust publication of the methodology and data.

Correction

2010-09-01

In the August 2010 issue of the Journal of Vascular Surgery (Volume 52, Issue 3), the Trans-Atlantic Debate article entitled “Asymptomatic carotid artery stenosis—Medical therapy alone versus medical therapy plus carotid endarterectomy or stenting” erroneously left Dr. Jean-Baptiste Ricco off of the article as co-section editor. Thomas L. Forbes, MD, and Jean-Baptiste Ricco, MD, PhD, are co-section editors for this article.

Editorial Board

2010-09-01

Information for authors

Anton N. Sidawy, Bruce A. Perler — 2010-09-01

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

2010-09-01

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

2010-09-01

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