Journal of Vascular Surgery

D. Emerick Szilagyi, MD, 1910-2009; Editor, 1984-1990

Daniel J. Reddy, Alexander D. Shepard — 2010-02-01

Early morning November 1, 2009 Vascular Surgery lost an original. With the passing of D. Emerick Szilagyi just a few months shy of his 100th birthday our specialty, surgical organizations, professional journals, clinics, operating suites and patients lost a peerless and long-serving leader. The authors along with legions of his professional colleagues, fellows and patients lost a mentor and friend ().

Contemporary results of standard open repair of acute traumatic rupture of the thoracic aorta

Alain Verdant — 2009-11-02

Background: Open repair of acute traumatic rupture of the thoracic aorta has been the standard of care for the past half century. Traditional criteria of operative success have been patient survival and prevention of spinal cord ischemia. Historical series have reported a variability of surgical results with relation to the variety of operative approaches. This study aims to update the results obtained with a uniform surgical technique based on a systematic utilization of distal perfusion during aortic cross-clamping.Methods: During a 35-year period (1974-2009), 138 consecutive patients with an acute traumatic rupture of the thoracic aorta were repaired with a Dacron graft interposition through a standard left thoracotomy. All patients received a method of circulatory support. A passive 9-mm Gott shunt inserted between the ascending and the descending aorta and delivering a median flow of 3 L/min was used in the first 40 cases. A partial left heart bypass realized from the left atrium to the descending aorta and driven with a centrifugal pump was used in the last 98 consecutive cases. A median flow of 4 L/min was recorded. Mean age of the patients was 27 years and 90.6% of them had associated injuries for a calculated mean ISS of 44.Results: Two outcome variables were analyzed: hospital mortality and postoperative spinal cord ischemic injury. Overall hospital mortality is 5% (7/138 patients). This was improved from 7.5% (3/40) in patients perfused with the Gott shunt to 4% (4/98) in patients protected with the left heart bypass and lowered to 1.5% (1/68) in the last 68 patients. Among 134 cases with an intact preoperative spinal cord, one patient (0.7%) developed a new paraplegia due to a nonfunctional Gott shunt. Among 98 patients perfused with a centrifugal pump-driven left heart bypass, none of the 97 patients (0%) with a preoperative intact spinal cord developed a spinal cord ischemic deficit.Conclusion: Conventional open surgical repair of acute traumatic rupture of the thoracic aorta performed with an orderly monitored circulatory support can be accomplished with a very low rate of mortality and spinal cord injury. Compared with the Gott shunt, a left heart bypass propelled with a centrifugal pump is technically a more versatile method of perfusion, and it provides higher hemodynamic performance.

Invited commentary

Ron Balm — 2010-02-01

Patients with traumatic aortic rupture (TAR) were traditionally treated by conventional open repair. A major improvement in open repair was the introduction of distal aortic perfusion as opposed to the “clamp and sow” technique. It resulted in better survival and fewer complications such as paraplegia.

Endovascular repair of ruptured thoracic aortic aneurysms is associated with high perioperative mortality and morbidity

2010-02-01

Purpose: To analyze early and midterm results after endovascular treatment of ruptured thoracic aortic aneurysms (rTAA).Methods: Between January 1997 and January 2009, a total of 236 patients received thoracic aortic repair in our institution; 23 patients (14 men; median age, 75 years; range, 60-88 years) due to a ruptured thoracic aortic aneurysm (rTAA). Rupture was defined according to computed tomography angiograpy (CTA) criteria with definite sign for hemorrhage outside the aortic wall. Patients with symptomatic TAA but with normal CT scans were excluded. A retrospective analysis of these patients was performed. Median follow up was 28 months (range, 0.1-82.5 months) and included serial aortic imaging at discharge, six, and 12 months and annually thereafter.Results: Technical success rate was 87%. The overall in hospital mortality was 48% with predominantly (50%) cardiac complications. Neurological complications occurred in three patients, two patients suffered from a transient ischemic attack (TIA)/stroke, and one patient experienced paraplegia after early conversion to open surgery. Primary endoleaks were seen in four of 25 patients (16%); no secondary endoleak was observed. Early conversion was necessary in two patients caused by an aortoesophageal fistula. The one- and three-year survival rates were 37.3% and 29.9% with no aortic or procedure-related death during follow up. Reintervention was necessary in four of 25 patients (16%). Cox regression analysis revealed preoperative renal insufficiency (hazard ratio [HR] 5.85, P = .0073) as an independent predictor of perioperative death.Conclusions: The endovascular treatment of ruptured thoracic aortic aneurysms is associated with a high perioperative mortality and morbidity as well as poor midterm survival. Renal insufficency proved to be an independent risk factor for perioperative death.

Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms

2009-11-25

Background: The mortality of ruptured abdominal aortic aneurysm (rAAA) has decreased 3.5% per decade in the last 50 years to a current rate of 40%-50%. Reports have indicated that endovascular repair (EVAR) is feasible for rAAA and may offer potential benefits over open repair. We examined the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day multicenter outcomes for EVAR vs open rAAA repair.Methods: Patients that underwent rAAA repair in the NSQIP database from 2005 to 2007 were identified through a combination of Current Procedural Terminology (CPT) codes and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses. Preoperative comorbidities, operative duration and transfusion, and 30 day outcomes were evaluated using t tests or Chi-squared tests depending on the variable. A separate multivariable regression was performed for each outcome adjusting for all independently predictive preoperative and intraoperative risk factors.Results: A total of 427 patients were identified and 76.8% of patients underwent open repair. The open repair groups exhibited lower albumin levels and higher percentage of patients with preoperative hematocrit (Hct) <38% and need for preoperative ventilation. The requirement for preoperative blood transfusion was similar. Patients undergoing open repair had much higher intraoperative transfusion requirements (11.8 ± 8.9 vs 4.2 ± 6.0 red blood cell units, P < .001). After adjustment for preoperative mortality risk factors, the mortality risk was higher for open repair versus EVAR (odds ratio 1.67, 95% confidence interval [CI] 0.91-3.05, P = .096) but did not reach significance. After similar adjustment the composite morbidity odds ratio for open repair versus EVAR was 1.82 (95% CI 1.11-2.99, P = .018) and the pulmonary adverse events odds ratio was 1.99 (95% CI 1.22-3.25, P = .006). Risks for the other outcomes were not significant.Conclusions: Composite 30-day morbidity risk is lower after EVAR vs open repair of rAAA. Open repair is associated with increased transfusion requirements. Performance of EVAR in rAAA patients with favorable anatomy could potentially result in improved outcome as compared with open repair.

Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair

2009-10-23

Objective: Patients undergoing repair of thoracoabdominal (TAA) or visceral aortic segment aneurysms typically require reconstruction of the renal arteries. The use of balloon expandable stents (BES) has been proposed as an alternative to endarterectomy or bypass for renal artery reconstruction (RAR) during open aortic aneurysm repair. We report technical aspects and long-term patency data for this method of right RAR during complex open aortic aneurysm repair.Methods: During the interval July 1, 2005 to December 31, 2007, a total of 67 patients underwent right RAR using a BES during concomitant TAA (type I: n = 2 [2.9%], type II: n = 8 [11.9%], type III: n = 13 [19.4%], and type IV: n = 22 [32.8%]), juxtarenal (n = 9 [13.4%]) or suprarenal (n = 13 [19.4%]) AAA repair. Indications for RAR were orificial stenosis (n = 21 [31%]) and/or technical considerations referable to the proximal aortic suture line. Patency of the renal stent was evaluated in patients with computed tomography angiography using three-dimensional reconstruction or with abdominal duplex evaluation at follow-up.Results: The mean patient age was 75.1 years, 54.4% were male, and 18% of operations were in nonelective circumstances. Twenty-seven (39%) out of 67 patients had a preoperative creatinine level ≥1.4 mg/dL. Two patients (2.9%) developed permanent renal failure postoperatively (neither related to renal artery occlusion). Mean radiologic follow-up was 405 days (11-1281) with 98% stent patency noted. One patient had an early stent occlusion noted at 1 month. An additional patient was noted to have a nonflow-limiting dissection distal to the renal stent, and another was noted to have distal migration of the stent beyond the renal ostium; however, these findings were clinically silent.Conclusions: The use of BES during complex open aortic aneurysm repair affords a rapid and durable mode of RAR, obviating the need for endarterectomy and its associated technical complications.

Invited commentary

Joseph J. Ricotta — 2010-02-01

Management of right renal artery reconstruction during complex aortic aneurysm repair, particularly through a flank or thoracoabdominal exposure, can be challenging and may require orificial endarterectomy for stenotic lesions as well as incorporation of the right renal artery into the suture line as a button, most commonly in conjunction with the superior mesenteric and celiac arteries. The use of intraoperative balloon-expandable stents (BESs) in the visceral arteries during open thoracoabdominal aneurysm repair was first described in 2004 by Lemaire et al, who reported 93 patients. In that study, however, only 9% of the patients had postoperative imaging. In the current study, Patel et al describe their technique and midterm results in 67 patients who underwent BES placement into the right renal artery during open repair of thoracoabdominal, suprarenal, and juxtarenal aortic aneurysms.

Predicting embolic potential during carotid angioplasty and stenting: Analysis of captured particulate debris, ultrasound characteristics, and prior carotid endarterectomy

2009-12-14

Introduction: Extracranial carotid stenoses exhibit significant variance in embolic potential, with restenotic lesions having a particularly low propensity for embolization. This study sought to identify characteristics associated with increased generation of embolic debris during carotid angioplasty and stenting (CAS).Methods: Captured particulate was available for analysis in 56 consecutive patients. Demographics were mean age, 74 years (range, 60-94 years); mean stenosis, 88% (range, 70%-99%); symptomatic, 27%; prior carotid endarterectomy (CEA), 27%; prior radiotherapy, 7%. Plaque echogenicity, heterogenicity, ulceration, and irregularity were assessed with B-mode duplex ultrasound analysis. Gray scale median (GSM) was calculated from normalized B-mode VHS video recordings. Calcification and degree of stenosis were determined angiographically. Captured particulate debris was evaluated for total number; number >200 μm, >500 μm, >1000 μm; mean and median size. Hematoxylin and eosin, trichrome, and von Kossa stains were used for histologic analysis of captured material.Results: Restenotic carotid stenoses after prior CEA generated minimal embolic debris compared with primary stenoses. Four of 15 patients (27%) with restenotic lesions demonstrated embolic particles; all debris was <500 μm. All 41 patients with primary stenoses had some embolic debris; particulate size was >200 μm in 91%, >500 μm in 72%, and >1000 μm in 43%. In primary lesions, the number and size of captured particulate correlated with GSM and with the combined ultrasound findings of echogenicity, heterogenicity, and luminal irregularity/ulceration (P < .02, 95% confidence interval, 4.5-27.6). None of these ultrasound factors correlated independently with embolic particulate (P = NS). Patients aged >70 years exhibited more total particles (8.1 vs 2.3, P = .008) and increased mean particle size (370 vs 157 μm, P = .02). No significant correlation was observed between the number and size of captured embolic particulate and any other variable (stenosis percentage, prior radiotherapy, preprocedural symptoms, periprocedural symptoms, and calcification). Histologically, the embolic debris consisted of extensive amorphous, acellular proteinaceous material. Calcium debris in the embolic particulate was associated with heavily and moderately calcified lesions.Conclusions: Considerable variation exists in the number and size of embolic particles generated during CAS. Embolic potential is positively correlated with lesion GSM and the combination of lesion echogenicity, heterogenicity, and irregularity. Restenosis after prior CEA is associated with minimal embolic particulate generation, suggesting that embolic protection may not be necessary for CAS of restenotic lesions.

Open surgical reconstruction of the internal carotid artery aneurysm at the base of the skull

2010-02-01

Objectives: Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report a standardized surgical technique of ICA reconstruction with long-term results.Methods: Between 1988 and 2005, 13 patients (11 men; age 18 to 76 years, mean 42.6 years) underwent lateral skull base approach with cervical-to-petrous carotid artery bypass for repair of ICA aneurysms. Principal elements of the technique were: partial resection of the parotid gland without rerouting of the facial nerve; luxation of mandibula; drilling of the bone.Results: The 13 patients had unilateral aneurysm of the ICA at the base of the skull. Four aneurysms were of atherosclerotic origin; six fibromuscular dysplasia; two post-traumatic; one cause was undetermined. The mean diameter of the aneurysms was 12 mm (range, 7-21 mm). Twelve patients were symptomatic: six presented neurological events (four strokes, two transient ischemic attack [TIA]); two retinal events; three compressive symptoms (two Horner's syndrome and one paralysis of the glossopharyngeal nerve); one patient presented a visible pulsatile mass in the neck. One patient was asymptomatic. There were no post-operative deaths, one TIA, 13 transient palsies of the lower facial nerve, and one transient palsy of accessory nerve. Palsy of cranial nerves was partial and disappeared within a mean of 5.6 months (range, 1-10 months). The postoperative angiogram showed patency in all but one case (one asymptomatic thrombosis). During follow-up (mean, 152 months), there was one unrelated death, one focal epileptic seizure, and one controlateral TIA. In November 2008, duplex showed patency of all 11 grafts (one death, one thrombosis). At 10 years, the survival, cumulative stroke-free survival, ipsilateral stroke-free, and patency rates was were 90.9%, 100%, 100%, and 92.3%.Conclusion: Venous graft bypass from the cervical-to-petrous ICA can be performed safely with such an approach and produces durable satisfactory results.

Atrial fibrillation is associated with increased risk of perioperative stroke and death from carotid endarterectomy

Nancy L. Harthun, George J. Stukenborg — 2009-11-02

Background: Carotid endarterectomy is performed in high volume in the United States. Identifying patients with a higher risk of stroke and death after carotid endarterectomy can lead to modifications in care that would significantly reduce the occurrence of these events. This study evaluates whether atrial fibrillation is significantly associated with an increased risk of death or stroke for patients undergoing carotid endarterectomy.Methods: This retrospective cohort study uses multivariable logistic regression analysis to assess the relationship between atrial fibrillation and death and/or stroke after carotid endarterectomy. The study population is drawn from the National Inpatient Sample, 2005. All patients with a primary carotid endarterectomy and diagnosis of stenosis of precerebral arteries were included, except patients with concomitant open heart procedures. The main outcomes examined were in-hospital death and stroke, adjusted for age, gender, symptomatic status, and for comorbid disease.Results: Carotid endarterectomy was performed for 20,022 patients. Strokes occurred in 189 patients (0.94%), and death occurred in 59 (0.29%). Patients with atrial fibrillation had significantly higher adjusted odds of stroke or death (odds ratio = 2.45; P < .0001).Conclusion: Patients with atrial fibrillation have a substantially higher risk of stroke and death after carotid endarterectomy.

A comparative analysis of the outcomes of carotid stenting and carotid endarterectomy in women

2009-11-25

Objective: Randomized controlled trials (RCTs) of carotid endarterectomy (CEA) advised little benefit from surgery in women because of high operative risk. Whether these findings are also applicable to carotid angioplasty and stenting (CAS) is subject of investigation. Our aim was to determine the risk of perioperative and late complications related to CAS and CEA in women.Methods: Data from a single-center carotid surgery database including 1065 individuals with CAS (306 women and 759 men) and 1131 with CEA (325 women and 806 men) were analyzed in a consecutive series of patients. Perioperative risks of death, stroke, and local complications in women undergoing CAS and CEA were compared. Rates of restenosis >50% and stroke at 5 years in symptomatic and asymptomatic women were also assessed.Results: The perioperative risks of stroke or death were no different in women who underwent CAS and CEA women (1.9% vs 3.0%; odds ratio [OR] = 0.63; 95% confidence interval [CI], 0.20-1.7; P = .45) whether they were symptomatic or not. Other perioperative complications were also similarly distributed between the two groups of women. Life-table estimates of any periprocedural stroke/death and ipsilateral stroke at 5 years after the procedure did not differ between women with CAS and CEA (4.1% vs 8.1%; P = .18). Five-year rates of restenosis >50% were nonsignificantly higher in women after CEA than after CAS (1.8% vs 8.1%; P = .058).Conclusion: Women with carotid stenosis might have favorable early and late outcomes from CAS with complication rates similar and even lower than those attained with CEA. CAS, performed by trained operators, may be a valid primary choice for treatment of carotid stenosis, particularly in asymptomatic women for whom the risk of surgery seems to be higher. However, before claiming CAS for women, these results need to be confirmed by large RCTs.

Discussion

2009-11-25

Dr Marc Mitchell (Jackson, Miss). As I understand your data, it demonstrates good results with both carotid endarterectomy and carotid angioplasty and stenting in both men and women. I think the data makes a strong argument that women benefit from carotid interventions just as men do. On what basis do you conclude that carotid angioplasty and stenting is superior to endarterectomy in women?

Echolucent or predominantly echolucent femoral plaques predict early restenosis after eversion carotid endarterectomy

2010-02-01

Objective: Although the association between vulnerable lesions and cardiovascular events is well established, little is known about their relationship to postsurgery restenosis. To address this issue, we initiated a prospective, nonrandomized study to examine the femoral plaques on both sides in patients who were undergoing eversion carotid endarterectomy (CEA) and were longitudinally followed-up for early restenosis development.Methods: The final analysis enrolled 321 patients (189 women) with a median age of 67.0 years (interquartile range, 59.0-73.0 years), who underwent eversion CEA (2005 to 2007). Using duplex ultrasound scanning, we evaluated 321 common femoral atherosclerotic lesions on the day before CEA. A quantitative scale was used to grade the size of plaques as grade 1, one or more small plaques (<20 mm2); grade 2, moderate to large plaques; and grade 3, plaques giving flow disturbances. The plaque morphology in terms of echogenicity was graded as echolucent, 1; predominantly echolucent, 2; predominantly echogenic, 3; echogenic 4; or calcified, 5. The plaque surface was categorized as smooth, irregular, or ulcerated. The patients underwent carotid duplex ultrasound imaging at 6 weeks and at 6, 12, and 24 months after CEA. Mann-Whitney U test, χ2 test, and multivariate logistic regression were used for statistical evaluation.Results: Internal carotid artery restenosis of ≥50% was detected in 33 patients (10.28%) in the operated region. Neither the size (grade 1, P = .793; grade 2, P = .540; grade 3, P = .395) nor the surface characteristics of the femoral plaques (smooth, P = .278; irregular, P = .281; ulcerated, P = .934) were significantly different between the patients with and without carotid restenosis. Echolucent-predominantly echolucent femoral lesions were an independent predictor of recurrent carotid stenosis (adjusted odds ratio, 5.63; 95% confidence interval, 2.14-10.89; P < .001).Conclusion: Ultrasound evaluation of femoral plaque morphology before CEA can be useful for identifying patients at higher risk for carotid restenosis.

Preoperative functional status predicts perioperative outcomes after infrainguinal bypass surgery

2010-02-01

Objective: Infrainguinal surgical bypass (BPG) is a durable method for lower extremity revascularization, but is accompanied by significant 30-day morbidity and mortality (MM). The goal of this study is to relate preoperative functional status, a defined metric in the National Surgical Quality Improvement Program (NSQIP) database, to perioperative MM.Methods: Between January 1, 2005 and December 31, 2007, all patients who underwent BPG from the NSQIP private sector database were reviewed. The primary end-point was 30-day MM. Patients were stratified by preoperative functional status: independent (IND) vs dependent (DEP). Associated patient demographic/clinical data were analyzed using univariate and multivariate methods. Composite odds ratios were constructed with clusters of high-risk comorbidities.Results: There were 5639 BPG patients (4600 [81.6%] IND and 1039 [18.4%]) DEP. DEP patients were significantly older (71.6 ± 11.8 vs 66.8 ± 11.8 years; P < .0001), had more chronic obstructive pulmonary disease (COPD) (16.7% vs 11.4%; P < .0001), diabetes (54.2% vs 40.7%; P < .0001), dialysis dependence (16.4% vs 5.6%; P < .0001), and critical limb ischemia (64.6% vs 44.0%; P < .0001). DEP patients had a higher incidence of death (6.1% vs 1.5%; P < .0001) and major complications (30.3% vs 14.2%; P < .0001). DEP was an independent predictor of major complications (odds ratio [OR]: 2.0; 95% confidence interval [CI]: [1.7-2.4]; P < .0001) major systemic complications (2.5 [1.9-3.2]; P < .0001), major operative site complications (1.6 [1.4-1.9]; P < .0001) and death (2.3[1.6-3.4]; P < .0001). The combination of DEP with emergency surgery, Cr > 1.8, or rest pain increased the odds of major complications by five, seven, or 11-fold, respectively. The combination of DEP with hemodialysis, emergency surgery, or age ≥80 years increased the odds of death by 13, 38, or 87-fold, respectively.Conclusion: Preoperative DEP is significantly correlated with all adverse 30-day outcomes in BPG patients. Furthermore, when combined in high-risk composites with specific preoperative clinical variables, DEP is associated with prohibitive MM, thereby identifying patient cohorts that may be unsuitable for BPG.

Discussion

2010-02-01

Dr G. Patrick Clagett (Dallas, Tex). Would you recommend primary amputation in a patient who is functionally dependent and has other markers for poor outcome such as increased P III score and elevated CRP as we have heard from other papers this morning?

Functional status as a prognostic factor for primary revascularization for critical limb ischemia

H.C. Flu, J.H.P. Lardenoye, E.J. Veen, D.P. Van Berge Henegouwen, J.F. Hamming — 2010-02-01

Background: Lower extremity arterial revascularization (LEAR) is the gold-standard for critical lower limb ischemia (CLI). The goal of this study was twofold. First, we evaluated the long-term functional status of patients undergoing primary LEAR for CLI. Second, prognostic factors of long-term functional status and survival after primary LEAR for CLI were assessed.Methods: All primary LEAR procedures were analyzed. Patients were stratified by preoperative functional status: ambulatory (group I) vs nonambulatory (group II). Patients were followed-up after 3 and 6 years. Adverse events (AEs) were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. Associated patient demographic/clinical data were analyzed using univariate and multivariate methods.Results: There were 106 LEAR patients (group I: n = 42, 40% vs group II: n = 64, 60%). Group II patients were significantly older (75 vs 62 years; P = .00), were classified ASA 3-4 more frequently (78% vs 52%; P < .02), had more cardiac disease (n = 42, 66% vs n = 10, 24%; P = .00), renal disease (n = 26, 41% vs n = 7, 17%; P = .00), diabetes (n = 36, 56% vs n = 8, 19%; P = .00), hypertension (n = 47, 73% vs n = 13, 31%; P = .00) and severe CLI (n = 42, 66% vs n = 18, 38%; P < .01). Group II patients had a higher incidence of death (65.6% vs 14.3%; P = .00), minor AEs (n = 38, 26% vs n = 10, 22%; P = .00), surgical AEs (n = 48, 33% vs n = 12, 26%; P < .02) and systemic AEs (n = 24, 86% vs n = 4, 9%; P < .02). Also more unplanned reinterventions occurred in group II (n = 148, 76% vs n = 47, 24%; P = .00). Nonambulatory status was a multivariate independent predictor of nonambulatory status after LEAR during 6 years follow-up (odds ration [OR[: 21.47; 95% confidence interval [CI]: 2.76-166.77; P = .00). Pulmonary disease (OR: 7.49; 95% CI: 2.17-25.80; P = .00), not prescribing β-blockers (OR: 4.67; 95% CI: 1.28-17.03; P < .02), nonambulatory status (OR: 22.99; 95% CI: 6.27-84.24; P = .00), and systemic AEs (OR: 9.66; 95% CI: 1.84-50.57; P < .01) were independent predictors of death. Functional status was not improved in group II after long-term follow-up.Conclusion: Nonambulatory patients suffer from extensive comorbid conditions. They are accompanied with an increased occurrence of AEs, unplanned reinterventions, and poor long-term survival rates. Successful LEAR did not improve their functional status after 6 years. This emphasizes that attempts for limb salvage must be carefully considered in these patients.

Analysis of gender-related differences in lower extremity peripheral arterial disease

2009-12-18

Introduction: Gender-related differences continue to challenge the management of lower extremity (LE) peripheral arterial disease (PAD) in women. We analyzed the time-trends in hospital care of such differences.Methods: Data for patients with PAD from New York, New Jersey, and Florida state hospital inpatient discharge databases (1998-2007) were analyzed using univariate and multivariate regression analyses.Results: The 2.4 million PAD-related inpatient discharge records analyzed showed a slight decrease of inpatient procedures for both genders. Compared with men, women had 18% to 27% fewer PAD and 33% to 49% fewer vascular procedural hospitalizations (P < .0001). They were persistently more likely than men to be admitted emergently (56% vs 51% in 1998 and 57% vs 53% in 2007) and discharged to a nursing home. During the study period, the amputation rate declined by 36% in women and 21% in men with PAD, and similarly, open procedures decreased by 36% and 30%. Endovascular procedures, however, increased by 150% in women and 144% in men. Procedural mortality was 4.95% vs 4.37% for men (P < .0001). Female mortality rates were persistently higher after amputations (9.89 % vs 8.90%, P < .0001), open (5.49% vs 4.00%, P < .0001), and endovascular procedures (2.87% vs 2.10%, P < .0001). Time trends showed improved mortality for men and women, with a stable difference between the two.Conclusion: The analysis of representative state administrative databases of inpatient care records demonstrated improvements in mortality and amputation rates over time. However, a gender-related disparity in PAD outcomes remains that merits further investigation.

Discussion

2009-12-18

Dr Michael Costanza (Syracuse, NY): Gender differences in vascular disease have been described for at least 20 years and previous studies suggest that women fare poorly compared to men with respect to timely diagnosis, treatment provided, and surgical outcome. Whether this gender disparity still exists in the era of endovascular therapy remains unclear.

Predicting blood pressure response after renal artery stenting

2009-11-25

Background: Although technical success of renal artery stenting (RAS) is high and adverse events are infrequent, clinical success (improved blood pressure and renal function) and durability have been less predictable. Identifying those patients who will respond to RAS could improve overall outcomes of the procedure.Methods: This was a retrospective analysis of all patients who underwent RAS for treatment of renovascular hypertension (RVH) between 2001 and 2007 at Dartmouth-Hitchcock Medical Center. The primary outcome measure was blood pressure improvement or cure as judged by American Heart Association criteria. Estimated glomerular filtration rate (eGFR), number of antihypertensive medications, and survival were evaluated as secondary outcomes. Univariate and multivariate analyses were performed to identify factors associated with blood pressure improvement at the last follow-up.Results: During the 6-year period, 129 patients (179 renal arteries) underwent stent placement for RVH. Procedural complications occurred nine patients (7.0%). Average length follow-up was 1.5 years. Follow-up data were obtained in 122 patients (95%). At last follow-up, there were significant improvements in systolic blood pressure (161 vs 144 mm Hg, P < .001), diastolic blood pressure (80 vs 73 mm Hg, P < .001), and number of antihypertensive medications (3.1 vs 2.8, P = .034). The eGFR was improved in 16% of patients, stable in 60%, and worse in 24%. By multivariate analysis, a baseline eGFR <40 mL/min/1.73 m2 (odds ratio, 1.6; 95% confidence interval [CI], 1.0-2.9; P = .02) and female gender (OR, 1.3; 95% CI, 1.0-2.1; P = .04) were independent predictors of failure to achieve blood pressure improvement. By 2 and 4 years of follow-up, sustained blood pressure improvement was present in 67% of patients with a baseline eGFR of ≥40 mL/min/1.73 m2 and in 31% of patients with a baseline eGFR <40 mL/min/1.73 m2. During 2 years of follow-up, survival was similar between patients with sustained blood pressure response and those without.Conclusion: Patients treated for RVH who have a baseline eGFR of ≥40 mL/min/1.73 m2 demonstrate a better response to RAS at each follow-up interval, with a significant difference at 2 to 4 years, compared with patients with an eGFR <40 mL/min/1.73 m2.

Discussion

2009-11-25

Dr Matthew Edwards (Winston-Salem, NC). Good morning. I would like to thank the Society and the program committee for the opportunity to discuss this presentation on the topic of predicting long-term blood pressure responses following renal artery stenting. I would also like to congratulate Dr Beck on his presentation.

Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia

2009-11-05

Purpose: Open revascularization in patients with chronic mesenteric ischemia (CMI) is considered the gold standard. Percutaneous transluminal angioplasty and stenting (PTAS) is often reserved for patients not suitable for open revascularization. In our institute, endovascular revascularization is the first-choice treatment. The purpose of this study was to report the technical and clinical success rates after endovascular revascularization as the first-choice treatment in a series of 51 consecutive patients with CMI at a single tertiary vascular referral center.Methods: A retrospective review was performed of all consecutive patients with CMI who underwent PTAS from July 2001 to July 2008. Only symptomatic patients treated for atherosclerotic CMI were included. Patency was evaluated using computed tomography angiography (CTA). Kaplan-Meier curves were used to calculate patency rates of the treated mesenteric arteries.Results: Sixty mesenteric arteries (30 celiac trunks, 24 superior mesenteric, and 6 inferior mesenteric arteries) were treated in 51 patients (26 men). Major morbidity was 4%. After dissection of the superior mesenteric artery (n = 1) and brachial artery (n = 1), respectively, both patients underwent endarterectomy and patch plasty. In three arteries, the lesion could not be crossed endovascularly and they were deemed immediate intention-to-treat failures. The initial technical success rate was 93%. No 30-day mortality was observed. Median follow-up was 25 months. During follow-up, 2 patients died from intestinal ischemia. Complete symptom relief was achieved in 78% of patients. Primary 1- and 2-year patency rates were 86% ± 5% and 60% ± 9%, respectively; primary-assisted patency rates were 88% ± 5% and 79% ± 7%, respectively. During follow-up, 6 patients underwent open revascularization due to failure of PTAS.Conclusion: The initial technical success rate of PTAS as first-choice treatment of CMI is >90%. The 2-year primary patency rate dropped to 60%, but symptomatic in-stent stenoses could often be treated successfully with renewed endovascular techniques. Including one conversion, 14% of patients needed open revascularization during follow-up.

Invited commentary

Ahmed Abou-Zamzam — 2010-02-01

Fioole et al report 51 patients treated with percutaneous angioplasty and stenting (PTAS) for chronic mesenteric ischemia (CMI), reflecting the authors' transition towards a PTAS-first approach to CMI. They report very acceptable primary patency, secondary patency, and clinical success at 2 years of 60%, 79%, and 56%, respectively. This article is important, because the transition to endovascular-first treatment for CMI is not limited to this group but has been observed in many vascular practices. This report highlights the continued tradeoff of newer, less invasive treatments, and lower morbidity at the expense of durability and higher reintervention rates compared with open surgery.

Interventions for mesenteric vasculitis

2010-02-01

Objective: This study reviewed the outcomes of open and endovascular revascularization for mesenteric vasculitis (MV).Methods: We reviewed the clinical data of all patients who underwent revascularization for occlusive MV from 1984 to 2008. Patients treated for aneurysms or mucosal bleeding without ischemic symptoms were excluded. End points were early mortality and morbidity, survival, freedom from mesenteric symptoms, and patency. Outcomes of open reconstructions were compared with the results of 163 patients who underwent open operations for atherosclerotic disease.Results: There were 15 patients (13 females, 2 males) with a mean age of 38 years (range, 15-66 years). Etiologies were Takayasu's arteritis in 7, polyarteritis nodosa in 4, indeterminate in 3, and giant cell arteritis in 1. The celiac axis was affected in 13, superior mesenteric artery (SMA) in 13, renal arteries in 8, and the aorta in 4. Seven patients had active disease, and eight were in remission. Nine (60%) presented with symptomatic chronic (n = 8) and acute (n = 1) mesenteric ischemia. Six patients with asymptomatic disease underwent mesenteric revascularization during other aortic-based operations. Fourteen patients (93%) had 10 mesenteric bypasses (8 aortic based; 2 iliac), three had aortoplasties, of which two had mesenteric patch angioplasties, and one underwent arcuate ligament release with patch angioplasty. One patient (7%) underwent percutaneous transluminal angioplasty of SMA stenosis. There were no early deaths. Early complications occurred in three patients (20%) after open reconstruction, including gastrointestinal hemorrhage, ileus with re-exploration, and superior mesenteric vein thrombosis. Median follow-up was 22 months. One graft thrombosis in a patient with active disease was treated with redo bypass 74 months after aorta-celiac-SMA bypass. All patients were alive at 10 years, with similar expected survival compared with the general population (P = .69). Compared with patients with atherosclerotic disease, open reconstructions for MV had similar freedom from mesenteric symptoms (83% vs 75%, P = .80) and similar primary graft patency (83% vs 84%, P = .9).Conclusion: Mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, indeterminate, or giant cell arteritis. Open revascularization is durable and effective when needed.

Unexpected major role for venous stenting in deep reflux disease

Seshadri Raju, Rikki Darcey, Peter Neglén — 2009-12-14

Background: Treatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux.Methods: A total of 528 limbs in 504 patients, ranging in age from 15 to 87, underwent IVUS-guided iliac vein stent placement to correct obstruction over an 11-year period. The etiology of obstruction was nonthrombotic in 196 (37%), post-thrombotic in 285 (54%) limbs, and combined in 47 (9%). Clinical severity class of CEAP was C3 in 44%, C4,5 in 27%, and C6 in 25% of stented limbs. Deep venous reflux was present in all limbs, associated with superficial and/or perforator reflux in 69%. Reflux was severe in 309/528 (59%) limbs (reflux multisegment score ≥3) and 224/528 (42%) limbs had axial reflux. Venography and other functional tests had poor diagnostic sensitivity to detect obstruction, which was ultimately diagnosed by IVUS. The IVUS-guided iliac vein stenting was the only procedure performed and the associated reflux was left uncorrected.Results: There was no mortality; morbidity was minor. Cumulative secondary stent patency was 88% at 5 years; no stent occlusions occurred in nonthrombotic limbs. Cumulative rates of limbs with healed active ulcers, freedom of ulcer recurrence in legs with healed ulcers (C5), and freedom from leg dermatitis at 5 years were 54%, 88%, and 81%, respectively. Cumulative rate of substantial improvement of pain and swelling at 5 years was 78% and 55%, respectively. Quality of life improved significantly. Reflux parameters did not deteriorate after stenting.Conclusion: Iliac venous stenting alone is sufficient to control symptoms in the majority of patients with combined outflow obstruction and deep reflux. Partial correction of the pathophysiology in limbs with multisystem or multilevel disease can provide substantial symptom relief. Percutaneous stent technology in concert with other minimally-invasive techniques to address superficial and/or perforator reflux offers such partial correction in limbs with advanced CVI and complex venous pathology. Open correction of obstruction or reflux is now required only infrequently as a “last resort”.

Discussion

2009-12-14

Dr Harry Schanzer (New York, NY). The paper just presented by Dr Raju et al is extremely important because it challenges all the previous concepts of pathogenesis and treatment of chronic venous insufficiency. Dr Raju, you have really put upside down all our previous notions of venous disease. I have carefully followed your experience over the years. Initially, you reported excellent results with valvular reconstruction even in the setting of postphlebitic syndrome. Later on, you reported improved results with iliac vein stenting in the postphlebitic syndrome, and now you are presenting us with the treatment of primary valvular venous insufficiency by iliac vein stenting. This, if true, is really a revolutionary change in the conceptual understanding of the pathogenesis of CVI and its treatment. I have two questions with regards to your experience.

Invited commentary

Thomas W. Wakefield — 2010-02-01

Drs Raju, Darcey, and Neglen add more information about the important role of venous obstruction to the syndrome of chronic venous insufficiency (CVI) in patients with deep venous reflux disease. From my perspective, the most important findings of this study include: venous stenting improved the rates of healed ulcers, freedom of ulcer-recurrence rates in legs with healed ulcers (C5), and freedom from leg dermatitis; venous stenting improved pain and swelling at 5 years with no differences between nonthrombotic and post-thrombotic obstructions, limbs with severe vs moderate reflux, and limbs with axial and segmental reflux; venous stenting did not result in a deterioration of reflux parameters; and deep venous reflux can be initially ignored if it is combined with iliac vein obstruction.

Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers

Eugenio Brizzio, Felix Amsler, Bertrand Lun, Werner Blättler — 2009-11-02

Objective: To compare the proportion and rate of healing, pain, and quality of life of low-strength medical compression stockings (MCS) with traditional bandages applied for the treatment of recalcitrant venous leg ulcers.Methods: A single-center, randomized, open-label study was performed with consecutive patients. Sigvaris prototype MCS providing 15 mm Hg-25 mm Hg at the ankle were compared with multi-layer short-stretch bandages. In both groups, pads were placed above incompetent perforating veins in the ulcer area. The initial static pressure between the dressing-covered ulcer and the pad was 29 mm Hg and 49 mm Hg with MCS and bandages, respectively. Dynamic pressure measurements showed no difference. Compression was maintained day and night and changed every week. The primary endpoint was healing within 90 days. Secondary endpoints were healing within 180 days, time to healing, pain (weekly Likert scales), and monthly quality of life (ChronIc Venous Insufficiency Quality of Life [CIVIQ] questionnaire).Results: Of 74 patients screened, 60 fulfilled the selection criteria and 55 completed the study; 28 in the MCS and 27 in the bandage group. Ulcers were recurrent (48%), long lasting (mean, 27 months), and large (mean, 13 cm2). All but one patient had deep venous reflux and/or incompetent perforating veins in addition to trunk varices. Characteristics of patients and ulcers were evenly distributed (exception: more edema in the MCS group; P = .019). Healing within 90 days was observed in 36% with MCS and in 48% with bandages (P = .350). Healing within 180 days was documented in 50% with MCS and in 67% with bandages (P = .210). Time to healing was identical. Pain scored 44 and 46 initially (on a scale in which 100 referred to maximum and 0 to no pain) and decreased within the first week to 20 and 28 in the MCS and bandage groups, respectively (P < .001 vs .010). Quality of life showed no difference between the treatment groups. In both groups, pain at 90 days had decreased by half, independent of completion of healing. Physical, social, and psychic impairment improved significantly in patients with healed ulcers only.Conclusion: Our study illustrates the difficulty of bringing large and long-standing venous ulcers to heal. The effect of compression with MCS was not different from that of compression with bandages. Both treatments alleviated pain promptly. Quality of life was improved only in patients whose ulcers had healed.

Hemin prevents in-stent stenosis in rat and rabbit models by inducing heme-oxygenase-1

2009-12-18

Objective: The introduction of drug-eluting stents (DES) has largely added benefit to the percutaneous coronary intervention. Questions about the long-term safety of DES have been raised, however, particularly with respect to late stent thrombosis. Research efforts are now being directed toward therapeutics that can impede smooth muscle proliferation and promote vascular healing. Emerging data suggest that heme oxygenase-1 (HO-1), an inducible oxidoreductase enzyme system, can exert cytoprotective effects on endothelial cells and limit smooth muscle cell proliferation. We assessed the ability of hemin, a potent HO-1 inducer, to reduce in-stent stenosis without compromising re-endothelialization.Methods: Rat aorta and rabbit iliac arteries were stented. Animals received ongoing treated with intraperitoneal hemin (50 mg/kg) or vehicle. At 7 to 28 days after surgery, stented arterial segments were collected and processed for histologic, electron microscopy, or protein analysis.Results: In both models, treatment with hemin reduced neointima growth without compromising re-endothelialization of the stented arteries. In the rat aorta, analysis of protein expression at 7 and 28 days after stenting revealed that hemin increased HO-1 expression and limited the early inflammatory, apoptotic, and proliferative cellular events that are common to in-stent stenosis. Hemin treatment decreased the expression of the Ki-67 protein and the activity of key regulators of smooth muscle cell proliferation, including p42/44, RhoA, and up-regulated the expression of cyclin-dependent kinase inhibitors. The beneficial effects of hemin were abolished in the presence of tin-protoporphyrin IX, an HO inhibitor. Finally, treatment with tricarbonylchloro(glycinato)ruthenium(II), a carbon monoxide donor, reduced in-stent stenosis in the rat aorta, suggesting that carbon monoxide, a by-product of heme degradation, might contribute to the protective effect of hemin.Conclusion: These results suggest that HO-1 is important in limiting in-stent stenosis and can be regarded as a new therapeutic target.Clinical Relevance: Long-term outcomes of endovascular treatments have not been impressive due to vascular stenosis caused mainly by intimal hyperplasia. Questions have been raised about the long-term safety of drug-eluting stents, particularly with respect to late stent thrombosis. Accumulating data indicate a link between inflammation and in-stent stenosis as well as between delayed endothelialization and thrombosis. We demonstrated in an animal model that hemin, a compound used in the management of porphyria, induced heme oxygenase-1 and limited inflammation and in-stent restenosis without compromising endothelialization. Thus, heme oxygenase-1 may be considered as a novel target in the next generation of drug-eluting stents for preventing in-stent restenosis after endovascular therapies.

In vivo suppression of vein graft disease by nonviral, electroporation-mediated, gene transfer of tissue inhibitor of metalloproteinase-1 linked to the amino terminal fragment of urokinase (TIMP-1.ATF), a cell-surface directed matrix metalloproteinase inhibitor

2009-12-25

Background: Smooth muscle cell (SMC) migration and proliferation are important in the development of intimal hyperplasia, the major cause of vein graft failure. Proteases of the plasminogen activator (PA) system and of the matrix metalloproteinase (MMP) system are pivotal in extracellular matrix degradation and, by that, SMC migration. Previously, we demonstrated that inhibition of both protease systems simultaneously with viral gene delivery of the hybrid protein TIMP-1.ATF, consisting of the tissue inhibitor of metalloproteinase-1 (TIMP-1) and the receptor-binding amino terminal fragment (ATF) of urokinase, reduces SMC migration and neointima formation in an in vitro restenosis model using human saphenous vein cultures more efficiently than both protease systems separately. Because use of viral gene delivery is difficult in clinical application, this study used nonviral delivery of TIMP-1.ATF plasmid to reduce vein graft disease in a murine bypass model. Nonviral gene transfer by electroporation was used to avert major disadvantages of viral gene delivery, such as immune responses and short-term expression.Methods: Plasmids encoding ATF, TIMP-1, TIMP-1.ATF, or luciferase, as a control, were injected and electroporated in both calf muscles of hypercholesterolemic apolipoprotein E3-Leiden (APOE*3Leiden) mice (n = 8). One day after electroporation, a venous interposition of a donor mouse was placed into the carotid artery of a recipient mouse. In this model, vein graft thickening develops with features of accelerated atherosclerosis. Vein grafts were harvested 4 weeks after electroporation and surgery, and histologic analysis of the vessel wall was performed.Results: Electroporation-mediated overexpression of the plasmid vectors resulted in a prolonged expression of the transgenes and resulted in a significant reduction of vein graft thickening (ATF: 36% ± 9%, TIMP-1: 49% ± 5%, TIMP-1.ATF: 58% ± 5%; P < .025). Although all constructs reduced vein graft thickening compared with the controls, the luminal area was best preserved in the TIMP-1.ATF-treated mice.Conclusion: Intramuscular electroporation of TIMP-1.ATF inhibits vein graft thickening in vein grafts in carotid arteries of hypercholesterolemic mice. Binding of TIMP-1.ATF hybrid protein to the u-PA receptor at the cell surface enhances the inhibitory effect of TIMP-1 on vein graft remodeling in vitro as well as in vivo and may be an effective strategy to prevent vein graft disease.Clinical Relevance: Venous bypass graft failure is a serious clinical problem that occurs in up to 40% to 60% of patients after bypass surgery, and reinterventions are often required both in cardiac and peripheral vascular disease. Smooth muscle cell migration and proliferation in the vessel wall, mediated by proteases of the plasminogen activator system and matrix metalloproteinase system, are important in the development of vein graft disease. Nonviral gene transfer by intramuscular electroporation of the hybrid protein TIMP-1.ATF, consisting of the tissue inhibitor of metalloproteinase-1 (TIMP-1) and the receptor-binding amino terminal fragment (ATF) of urokinase, to inhibit these proteases directly at the cell surface, suppresses the development of vein graft thickening, without the major disadvantages of viral gene delivery such as immune responses and short-term expression, and therefore may be a potential therapeutic tool to improve vein graft disease.

Reactive oxygen species mediate functional differences in human radial and internal thoracic arteries from smokers

2009-12-25

Objective: Smoking not only increases the risk that coronary heart disease will develop but also morbidity and mortality in patients with known coronary atherosclerosis and after coronary artery bypass grafting. Excessive generation of reactive oxygen species (ROS) has been implicated as the final common pathway for the development of endothelial dysfunction in various cardiovascular risk factors. This study assessed the influence of smoking on two different human arteries routinely used as coronary artery bypass graft conduits.Methods: Isometric tension was recorded on discarded segments of human left internal thoracic artery (ITA) and the radial artery (RA) from smokers and nonsmokers.Results: The contractile response to endothelin-1 was significantly stronger in arteries from smokers than in those from nonsmokers. By contrast, endothelium-dependent relaxant responses to acetylcholine were attenuated in RA rings but enhanced in ITA rings from smokers. In additional experiments, 5-(&6)-chloromethyl-2′-7′-dichlorodihydro-fluorescein diacetate (DCDHF) was used to photochemically detect ROS by confocal imaging of intact ITA and RA. Enhanced production of ROS was induced by exposure of tissues to 28°C. While during exposure to 28°C, basal fluorescence emission was unchanged in ITA rings, it increased significantly in RA rings, indicating enhanced formation of ROS in this peripheral artery.Conclusions: Data suggest that smoking induces endothelial dysfunction by increasing vascular ROS production. Different levels of endogenous antioxidant enzyme activities and the degree of atherosclerotic changes might modulate physiologic and pharmacologic vasoreactivity and be responsible for decreased graft patency of RA compared with ITA conduits, especially in active smokers.Clinical Relevance: Attenuated responses to acetylcholine and enhanced production of reactive oxygen species in human radial arteries compared with internal mammary arteries have suggested that smoking induces endothelial dysfunction by increasing vascular reactive oxygen species production. Different levels of endogenous antioxidant enzyme activities in both arteries might be responsible for different functional changes. The present data suggest that the type of vessel chosen for coronary artery bypass grafting is important, and that especially in active smokers, radial artery conduits may lead to decreased graft patency and worse patient outcomes compared with internal thoracic artery conduits.

Protective effects of cold spinoplegia with fasudil against ischemic spinal cord injury in rabbits

2010-02-01

Objective: Paraplegia remains a serious complication after surgical repair of thoracoabdominal aortic aneurysms. The aim of this study was to evaluate the neuroprotective efficacy of fasudil, a Rho kinase (ROCK) inhibitor, by reducing the number of infiltrating cells in the ventral horn and increasing the induction of eNOS against ischemic spinal cord injury in rabbits.Methods: Eighteen Japanese white rabbits were divided into three groups: saline (group 1, n = 7, 4°C) and fasudil (group 2, n = 6, 4°C) were immediately infused into the isolated segmental lumbar arteries over 30 seconds after aortic clamping. Group 3 (n = 5) was the sham-operated group. Hind limb function was evaluated 4 and 8 hours, and 1 and 2 days after 15 minutes of transient ischemia. Cell damage was analyzed by hematoxylin and eosin staining and temporal profiles of endothelial nitric oxide synthase immunoreactivity were performed. The number of intact motor neuron cells and infiltrating cells in the ventral horn were compared.Results: Two days after reperfusion, group 2 and group 3 showed better neurologic function, a greater number of intact motor neuron cells, and a smaller number of infiltrating cells in the ventral horn than group 1. The induction of endothelial nitric oxide synthase (eNOS) was prolonged up to 2 days after reperfusion in group 2.Conclusion: These results indicate that fasudil has neuroprotective effects against ischemic spinal cord injury in rabbits by reducing the number of infiltrating cells in the ventral horn and prolonging the expression of eNOS.Clinical Relevance: Paraplegia or paralysis caused by spinal cord ischemia remains a devastating and unpredictable complication after descending and thoracoabdominal aortic surgery. This study has revealed that fasudil has a neuroprotective effect against ischemic spinal cord injury in rabbits. Inhibition of the Rho/Rho kinase pathway by fasudil reduces the number of infiltrating cells in the ventral horn and prolongs the expression of eNOS. In the near future, Rho kinase may be an important therapeutic target for paraplegia induced by spinal cord ischemia.

Recurrent popliteal vein aneurysm

2009-10-19

A 28-year-old female presented with a soft mass in the left popliteal fossa. She had a popliteal vein aneurysm repair 4 years ago. Magnetic resonance venography and ultrasound revealed a recurrent saccular aneurysm on the site of the repair. It measured 3 × 4 cm and had no thrombus. The aneurysm was resected, and as the vein had adequate length, it was primarily repaired with an end-to-end anastomosis. She was placed on Coumadin for 3 months. At follow-up, the vein was competent and free of thrombosis.

Recurrence of a popliteal venous aneurysm

Garietta Falls, Mohammad H. Eslami — 2009-10-19

We report the case of a 40-year-old man with a recurrent popliteal vein aneurysm diagnosed 2 years after initial lateral aneurysmectomy. Definitive management consisted of popliteal vein aneurysm resection and reconstruction with an interposition spiral vein graft. Our case suggests that aneurysm vein resection and interposition vein graft should be the preferred surgical option. Also, patients treated may benefit from longer follow-up in light of the potential morbidity from recurrence if undetected.

Invited commentary

Anthony J. Comerota — 2010-02-01

The cases reported by Falls and Eslami and Gasparis et al in this issue of the Journal of Vascular Surgery once again focus our attention on the rare entity of popliteal venous aneurysms. These are the first two reports on the repair of recurrent popliteal vein aneurysms. As is the case in so many patients before, pulmonary embolism was the initial clinical presentation in the patient reported by Falls and Eslami, with the popliteal venous aneurysm detected incidentally during the search for the source of the pulmonary embolus. The initial clinical presentation of the patient reported by Gasparis et al was not reported. Although still a rare condition, vascular surgeons are more likely to see popliteal venous aneurysms today, since duplex ultrasound is the diagnostic staple of suspected lower extremity venous disease.

Endovascular treatment of contained rupture of a superior mesenteric artery aneurysm resulting from neurofibromatosis type I

2009-10-15

A 31-year-old woman with neurofibromatosis type I (NF-I) came to our hospital with hypotension and abdominal pain. A computed tomography (CT) scan showed blood in the retroperitoneum and two saccular aneurysms in the superior mesenteric artery (SMA). The largest measured 2.5 cm in diameter. She was treated with placement of a covered stent in the SMA, and both aneurysms were excluded from the systemic circulation. Arterial aneurysms are rare in this disease, and rupture of an SMA aneurysm in this context had been reported only once. We report an unusual case of a contained rupture of an SMA aneurysm associated with NF-I, successfully treated with a covered stent.

Management of a nontraumatic extracranial internal carotid aneurysm with external carotid transposition

2009-09-27

Primary aneurysms of the extracranial internal carotid artery are exceptionally rare, with only a very few reports in the medical literature that are not related to known connective tissue disease or antecedent trauma. The natural history of these entities has not been precisely defined. Nevertheless, the embolic risk that an aneurysm at this location represents mandates prompt intervention when identified. We present the case of a 42-year-old female who was found to have a 3-cm aneurysm of the right extracranial internal carotid artery after seeing a physician for refractory headaches. In an austere environment with limited resources, this patient was successfully managed with the use of external carotid transposition to the distal internal carotid artery, cephalad to the aneurysm.

Thoracic endografting in a patient with hereditary hemorrhagic telangiectasia presenting with a descending thoracic aneurysm

2010-02-01

A 53-year-old woman with no classic risk factors for aneurysm disease presented with the sudden onset of chest pain and dyspnea. A large descending thoracic aortic aneurysm with focal type B dissection was identified and excluded by emergency thoracic endografting. Further postoperative evaluation revealed a history of epistaxis, perioral telangiectasias, hepatic hypervascularity, and a mutation in the gene expressing activin receptor-like kinase 1 (ALK1), leading to a diagnosis of hereditary hemorrhagic telangiectasia. Aortic aneurysms associated with hereditary hemorrhagic telangiectasia are extremely rare, and to our knowledge, this is the first report of thoracic endografting in this patient population.

High spatial resolution magnetic resonance imaging of cystic adventitial disease of the popliteal artery

2010-02-01

High spatial resolution magnetic resonance imaging (MRI) of patients with cystic adventitial disease can demonstrate connections between cysts in the adventitia and the adjacent joint, which is important for successful treatment. The inability to identify these during surgery can lead to a recurrence; thus, high spatial resolution MRI has the potential to affect therapy. This article presents the high spatial resolution MRI findings of cystic adventitial disease in a series of three consecutive patients and discusses the relevance of these findings to the etiology and therapy.

Symptomatic, acute aortocaval fistula complicating an infrarenal aortic aneurysm

William C. Pevec, Eugene S. Lee, Ramit Lamba — 2009-07-13

An 84 year-old man presented with 2 weeks of worsening back pain. At the referring hospital, he was noted to have serum transaminase levels of 600 to 1000 U/L. An ultrasound scan to evaluate his gallbladder was interpreted as showing a 5- to 6-cm ruptured aneurysm of the abdominal aorta. He was transferred for management of the aortic aneurysm.

Management of diabetic foot problems

Jeffrey Kalish, Allen Hamdan — 2009-10-23

Background: Diabetic foot problems and their complications are a medical and economic challenge to the health care system and require an aggressive multidisciplinary approach to achieve limb salvage. The goals of this review article are to delve into this comprehensive topic and summarize key points regarding diabetic foot problems from the perspective of the vascular specialist treating these patients.Methods: The MEDLINE database was searched to identify articles on this topic.Results: We found 112 relevant articles. These were used to provide current data on (1) the pathogenesis leading to diabetic foot lesions (ie, the etiologic triad of ischemia, neuropathy, and infection), (2) the clinical presentation of these foot lesions and their systemic manifestations, (3) the optimal methods of diagnostic evaluation, including noninvasive testing and arteriography, (4) treatment selection guidelines to help delineate which patients require revascularization, and (5) medical and interventional treatments, including prevention strategies, wound healing strategies, use of antibiotics, and endovascular and open surgical options for revascularization.Conclusions: The data presented in this review article allow vascular clinicians to optimize patient care and achieve effective limb salvage for this growing segment of the population.

Do no harm

Keith D. Calligaro — 2010-02-01

Thank you, Dr Makaroun, for your kind remarks. It has been an honor and privilege to serve as President of the Eastern Vascular Surgery this past year. During this address, I will be referring to the Hippocratic Oath, which is attributed to the great Greek physician sometime during 470-370 B.C. Many of us may not have reviewed the oath in quite some time. In part, it states “I swear in the presence of the Almighty and before my family, my teachers, and my peers that according to my ability and judgment I will keep this Oath and Stipulation. To reckon all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others … and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.” The first two sentences of the Oath mention some of the individuals whom I would like to briefly thank, namely my family, teachers, peers, past trainees, and partners.

Dealing honestly with an honest mistake

Nathan L. Liang, Mary E. Herring, Ruth L. Bush — 2009-12-18

A 70-year-old woman was admitted for a symptomatic left iliofemoral deep vein thrombosis. She underwent percutaneous mechanical thrombectomy, followed by overnight thrombolysis. The next day her clot had resolved, and a culprit left iliac vein stenosis was identified. After stent placement, a heparin infusion was initiated and the patient was taken back to the ward. At 11 the evening after the procedure, the resident on call was contacted to verify the written order. The resident stated that the heparin dose was to be 250 U/h; however, the nurse documented 2500 U/h and changed the infusion pump at the patient's bedside. At 5:30 the next morning, the resident was notified that the patient's partial thromboplastin time was >300 seconds and promptly shut off the heparin infusion. No noticeable adverse events occurred because of the high heparin dosing. The charge nurse was notified, as was risk management. What should the patient be told?

A survey of demographics, motivations, and backgrounds among applicants to the integrated 0 + 5 vascular surgery residency

2009-12-18

Objective: The 0 + 5 integrated vascular surgery (VS) residency has altered the training paradigm for future vascular specialists. Rising interest in these novel programs highlights our need to better understand the applicant pool. We compared demographics and surveyed recent applicants to our integrated program to gain more insight into their background and motivation for accelerated vascular training.Methods: Demographics and objective parameters were determined from all 65 applicants to the integrated VS program at Stanford University Medical Center and compared to 58 applicants interviewed by the general surgery (GS) program at Harbor-UCLA Medical Center by querying the Electronic Residency Application System for the programs in 2009. There was no overlap of applicants between programs. An anonymous, voluntary Web-based survey was sent to these cohorts with a response rate of 82% for VS applicants and 60% for GS applicants. Subjects were queried regarding their background, personal experience, prior exposure to VS, and motivations for residency specialty selection.Results: Applicants to integrated VS programs tended to be older, were less likely to be from a US medical school, had a higher number of publications, and a higher percentage of cardiovascular-related publications than the GS applicants. When stratified by the 27 VS applicants (41%) that were offered an interview, this highly selected and desirable group for training was nearly 40% female, more likely to have an additional degree (PhD, master's), just as likely to be in the top quartile of their medical school class (60%), and score equally well on standardized board examinations (90th percentile) than the top GS applicants offered interviews. Survey data revealed that the majority of career choices (65%) were made during the third and fourth years of medical school. Factors most strongly influencing the decision to choose VS as a career were endovascular technologies/devices, challenging open vascular operations, clinical rotations on vascular surgery, the aging patient population, and perceived need for vascular surgeons and vascular surgeon mentorship. The most common reasons cited for particularly pursuing an integrated 0 + 5 VS training program were (1) more focused training/integration of cardiovascular medicine, (2) interest in catheter-based endovascular therapies, and (3) shorter time in training. Of the GS applicants, 58% indicated they would be interested in applying to an integrated residency in their subspecialty of interest, and 45% listed vascular surgery as a potential fellowship option after general surgery.Conclusion: Applicants to 0 + 5 integrated vascular residencies were more likely to have rotated on a vascular surgery service, observed vascular cases, identified a vascular surgery mentor, and been actively involved in cardiovascular research. The quality of the top VS applicant based on class rank and test scores is comparable to the top GS applicants, yet the VS applicant has a higher percentage of advanced degrees, more publications, and more involvement in cardiovascular research. Institutional strategies to increase medical student exposure to vascular surgery clinically and via research programs will optimize our ability to attract and train the best candidates in these new training programs.

Discussion

2009-12-18

Dr John Corson (Albuquerque, NM). It is interesting to see data on this subject. My only question is, how many of the people who are applying for the 0 − 5 vascular program have been in some noncategoric position in a general surgery program but failed to make the grade for retention in general surgery? Obviously, you selected the best out of the group of applicants. What have the majority of the individuals who applied been doing since they left medical school?

A total laparoscopic technique for endovascular thoracic stent graft deployment

Ricardo Yoshida, Ralf R. Kolvenbach, Zhidong Ye, Winston Yoshida — 2009-12-31

Background: Limitations of endovascular thoracic aneurym treatment include small, tortuous, or severely calcified iliac arteries. We present our experience with a total laparoscopic access to deploy thoracic endografts.Methods: A total laparoscopic left retrocolic approach was used in all cases. A Dacron conduit was laparoscopically sutured to either the iliac artery or to the aorta directly. The endograft was inserted through this conduit. After graft deployment, the Dacron prosthesis was tunneled to the groin and anastomosed with the femoral artery.Results: The laparoscopic procedure could successfully be performed in 11 patients. In six cases, the aorta was used as an access and in five patients, the iliac arteries were preferred. In one of these cases, the right iliac artery was used for deployment of the endograft. After successful aorto- or ileo-femoral bypass grafting, all patients had an improvement of their ankle brachial index postoperatively. The mean operative time was almost four hours, including laparoscopy, laparoscopic anastomosis, endograft deployment, and femoral artery anastomosis or profundaplasty.Conclusion: Totally laparoscopic assisted graft implantation in aorta or iliac arteries provides a safe and effective access for the endovascular delivery system. However, further evaluation and long follow-up are necessary to ensure the potential advantages of this technique. It is a less invasive option to overcome access-related problems with thoracic endograft deployment, giving the patient the advantage of a totally minimal invasive procedure.

Future of vascular surgery is in the office

Krishna M. Jain, John Munn, Mark Rummel, Sarat Vaddineni, Chris Longton — 2010-02-01

Objective: The practice of vascular surgery is under pressure from various specialties and payers. Our group started office-based procedures in May 2007. This article reports our study of the effect of this change on our case volume, office revenue, and the financial impact on the health care system.Methods: Between May 1, 2006, and April 30, 2007 (period 1), and between June 1, 2007, and May 31 2008 (period 2), 3041 and 3351 cases, respectively, were performed. In period 1, only venous cases could be done in the office. Before arteriogram, serum levels of urea nitrogen and creatinine were obtained. The number of percutaneous cases done in the hospital and office setting was analyzed, and revenue was calculated based on the 2008 Medicare fee schedule for our region. Amputation and mortality rates at 30 days were documented. Hospital DRG payment schedule was obtained.Results: In period 1, 670 (22% of total) percutaneous procedures were performed compared with 1502 (44.8%) in period 2, a twofold increase. In period 1, 1.5% of total cases were done in the office compared with 31% in period 2. There was a fivefold increase in revenue from these procedures. No deaths or amputations occurred as a result of procedures performed in the office. No anesthesiologist's expense and minimal preprocedural expenses were incurred. Total payment by Medicare, DRG payment to the hospital, and the physician component were higher in all the cases.Conclusions: A vascular surgery practice can benefit from office-based procedures. Procedures can be done safely. It results in an increase in the number of percutaneous procedures and revenue with a significant savings to the health care system. Surgeons can control their schedule. Every vascular surgeon should consider doing these procedures in office.

Discussion

2010-02-01

Dr Mark Adelman (New York, NY). Certainly, many of us believe that there are many patients and many procedures that are best done in the office setting. The revenue stream that you report in your presentation is quite dramatic. You also presented architects sketches and an elaborate infrastructure that you have grown in that office. You didn't comment much on the expense side of the balance sheet. It seems like a very large undertaking to bring all that clinical space and support into the office setting. I wonder if you could comment on how long it took you to amortize the expenses associated with this office-based practice to the point where you were both offering better case, and demonstrating a profitable business. Could you offer us some details of your business plan?

Perioperative β-blockers for vascular surgery patients

Benjamin S. Brooke — 2009-12-18

Perioperative β-blocker therapy has been a heavily investigated and controversial topic during the past decade. Prior national consensus statements that recommended the routine use of these medications in patients undergoing high-risk surgical procedures have been called into question because of the results of recent clinical trials that involved heterogeneous groups of surgical patients. This article reviews the evidence for perioperative β-blocker usage as it pertains to patients undergoing vascular surgery procedures. The weight of evidence suggests that β-blockers lower the perioperative risk of myocardial ischemia or infarction and cardiovascular death among patients with clinical risk factors undergoing major vascular surgery. However, there appears to be a concurrent risk of adverse events associated with these medications if patients are not monitored properly during the perioperative period. Perioperative β-blockers should continue to occupy a prominent role in the therapeutic armamentarium for improving outcomes among high-risk patients undergoing major vascular surgery.

Open surgical reconstruction of the internal carotid artery aneurysm at the base of the skull

Sean P. Roddy — 2010-02-01

This manuscript discusses one center's experience with treatment of extracranial internal carotid artery (ICA) aneurysms at the base of the skull. All patients had reconstruction with venous conduit and significant neck dissection, with drilling of the external auditory canal to expose the first vertical intrapetrous segment of the ICA. The authors conclude that the procedure can be done safely and with durable results.

Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers

Sean P. Roddy — 2010-02-01

The authors evaluate healing, pain, and quality of life when patients are treated for recalcitrant venous leg ulcers with low-strength medical compression stockings or traditional bandages. They identify no difference among therapies but acknowledge improvement in quality of life only for those patients who experienced ulcer healing.

Botox Therapy for Ischemic Digits

M.W. Neumeister, C.B. Chambers, M.S. Herron — 2010-02-01

Conclusion: Botox appears to provide improvement in digital perfusion and pain reduction in patients with Raynaud's syndrome when conservative management fails. Summary: Digital ulceration associated with Raynaud's syndrome is painful, difficult to treat, and frequently results in patient debilitation and chronic depression. Reports by Sycha and Van Beek have indicated potential benefit for patients with ischemic digits with local injection of botulinum toxin (Euro J Clin Invest 2004;34:312-3; Plast Reconstr Surg 2007;119:217-26). This was a retrospective observational study on outcomes of 19 patients with Raynaud's syndrome treated with botulinum toxin. All patients had chronic ischemic hand pain, and vascular studies had ruled out proximal occlusive disease and underlying disorders, including carpal tunnel syndrome, diabetes, renal failure, rheumatoid arthritis, hypothenar hammer syndrome, scleroderma and mixed connective tissue disease as well as lupus. Thirteen patients had chronic finger ulcers. Botox (50 to 100 U) was injected into the palm around each involved neurovascular bundle. Preinjection and postinjection laser Doppler studies were performed in most patients to assess potential changes in digital blood flow.

Dabigatran Versus Warfarin in the Treatment of Acute Venous Thromboembolism

S. Schulman, C. Kearon, A.K. Kakkar, RE-COVER Study Group — 2010-02-01

Conclusion: A fixed dose of dabigatran, an oral anticoagulant that does not require monitoring, is as effective as warfarin in the treatment of acute venous thromboembolism (VTE) and has a similar safety profile.

Heparin Induced Thrombocytopenia and Thrombosis in a Tertiary Care Hospital

M. Ban-Hoefen, C. Francis — 2010-02-01

Conclusion: The occurrence of heparin-induced thrombocytopenia (HIT) can be decreased by reducing the exposure to unfractionated heparin. The diagnosis can be improved by reporting the optical density of the enzyme-linked immunosorbent assay (ELISA) test result.

Prediction of Hypertension Improvement After Stenting of Renal Artery Stenosis: Comparative Accuracy of Translesional Pressure Gradients, Intravascular Ultrasound, and Angiography

M.A. Leesar, J. Varma, A. Shapira — 2010-02-01

Conclusion: A hyperemic systolic pressure gradient ≥21 mm Hg predicts improvement in hypertension after stenting of renal artery stenosis. Summary: Correlation is poor between the percentage of renal artery stenosis measured by renal angiography and translesional pressure gradients across the renal artery stenosis. It is postulated therefore that the discordance between procedural and clinical success in the treatment of renal artery stenosis may, at least in part, stem from the limitations of angiography and the assessment of the significance of renal artery stenosis. The authors therefore sought to compare the diagnostic accuracy of renal artery translesional pressure gradients, intravascular ultrasound (IVUS) imaging, and angiographic parameters in predicting hypertension improvement after stenting of renal artery stenosis. Their hope was to establish criteria where stenting of the renal artery can be justified by improved hypertension control.

Racial and Ethnic Disparities in Outcomes and Appropriateness of Carotid Endarterectomy: Impact of Patient and Provider Factors

E.A. Halm, S. Tuhrim, J.J. Wang — 2010-02-01

Conclusion: Minorities have worse outcomes and higher rates of inappropriate carotid endarterectomy (CEA). Summary: There are many variables that lead to inequities in quality and outcomes of health care. In particular, access to care, particularly adequate insurance, appears to be a major driver of disparities in care. However, inequities exist even among well-insured patients. Possible drivers of inequities in health care include racial and ethnic differences and underlying social demographic characteristics, as well as severity of comorbid illnesses and overall disease burden. Minority patients may also receive care by physicians and in hospitals with lower levels of cultural competence than would be ideal. There is therefore a current emphasis on identifying how patients' disease burden and physician or hospital factors, or both, can contribute to disparities among care in minority patients.

Revascularization vs Medical Therapy for Renal-Artery Stenosis

The ASTRAL Investigators — 2010-02-01

Conclusion: There is no significant clinical benefit from renal artery revascularization in patients with renal artery atherosclerotic disease. Summary: Renal artery stenosis is associated with chronic kidney disease and hypertension. It is, however, not clear that these associations are causal. In fact, three small randomized control trials have showed no benefit of renal artery angioplasty compared with medical therapy (Hypertension 1998;31:823-9; J Hum Hypertens 1998;12:329-35; N Engl J Med 2000;342:1007-14). These studies were small and underpowered to detect potentially clinically worthwhile improvements in renal function, blood pressure, or mortality rates. The current Angioplasty and Stent for Renal Artery Lesions (ASTRAL) trial is a randomized unblinded trial in which 806 with atherosclerotic renal vascular disease were assigned to undergo medical therapy alone or renal revascularization (renal angioplasty with or without a stent and without renal protection) in addition to medical therapy. Renal function measured by the reciprocal of the serum creatinine level (a value that has a linear relationship with creatinine clearance) was the primary outcome measure. Secondary outcomes were the times to renal and major cardiovascular events, death, and blood pressure. Medium follow-up was 34 months.

Secondary Intervention After Endovascular Abdominal Aortic Aneurysm Repair

M.F. Conrad, A.B. Adams, J.M. Guest — 2010-02-01

Conclusion: Secondary interventions are common after endovascular aneurysm repair but do not adversely affect aneurysm related death or overall actuarial 5-year survival. Summary: A substantial number of secondary interventions are performed in patients who have undergone endovascular aneurysm repair (EVAR). Rates of secondary intervention range from 10% to 18%, with most problems addressed with endovascular procedures. The authors sought to determine the indications for secondary interventions after EVAR in their institution and the effect of these interventions on long-term survival.

Strokes After Cardiac Surgery and Relationship to Carotid Stenosis

Y. Li, D. Walicki, C. Mathiesen — 2010-02-01

Conclusion: There is no causal relationship between significant carotid stenosis and stroke after cardiac surgery. Summary: There are potentially multiple mechanisms for stoke after a cardiac surgical procedure, including carotid artery stenosis, cardiac arrhythmia, aortic atherosclerosis, transient hypercoagulable states, and hypertension. These multiple and often coexisting causes make studying the mechanism of stroke after cardiac surgery difficult. Estimates are that in 2001, >5000 combined cardiac and carotid operations were performed in the United States (Neurology 2007;63:195-97). Recent analyses suggest increased stroke and death after combined procedures (Neurology 2007;68:195-7; Neurology 2005;64:1435-7). In this study of 4335 patients undergoing coronary artery bypass grafting or aortic valve replacement, or both, the authors sought to define the incidence and arterial distribution of stroke after the procedure.

Systematic Preoperative Coronary Angiography and Stenting Improves Postoperative Results of Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease: A Randomised Controlled Trial

2010-02-01

Objective: To evaluate the usefulness of systematic coronary angiography followed, if needed, by coronary artery angioplasty (percutaneous coronary intervention (PCI)) on the incidence of cardiac ischaemic events after carotid endarterectomy (CEA) in patients without evidence of coronary artery disease (CAD).

Clinical Results of Carotid Denervation by Adventitial Stripping in Carotid Sinus Syndrome

R.J. Toorop, M.R. Scheltinga, M.C. Huige, F.L. Moll — 2010-02-01

Aims: Older patients with spells of syncope may suffer from a carotid sinus syndrome (CSS). Patients with invalidating CSS routinely receive pacemaker treatment. This study evaluated the safety and early outcome of a surgical technique termed carotid denervation by adventitial stripping for CSS treatment.

An Analysis of 50 Surgically Managed Penetrating Subclavian Artery Injuries

S. Sobnach, A.J. Nicol, H. Nathire, S. Edu, D. Kahn, P.H. Navsaria — 2010-02-01

Objectives: The surgical management and outcome of penetrating subclavian artery (SCA) injuries is presented in this article. Design: A retrospective chart review is used to detail the management and outcome of penetrating SCA injuries.

Repair of Arterial Injury after Blunt Trauma in the Upper Extremity–Immediate and Long-term Outcome

J. Klocker, J. Falkensammer, L. Pellegrini, M. Biebl, T. Tauscher, G. Fraedrich — 2010-02-01

Objective: In contrast to upper extremity stab and gunshot wounds, data on management and outcome in blunt trauma (BT) are limited by small numbers and short follow-up periods.

Endovascular Repair of Thoracoabdominal Aortic Aneurysms

2010-02-01

Objectives: To evaluate the early outcomes following thoracoabdominal aortic aneurysm (TAAA) repair utilising fenestrated and branched endografts. Design and materials and methods: A prospective analysis of all patients undergoing endovascular repair of TAAA in a single academic centre. All patients were deemed unfit for open surgical repair. Customised endografts were designed using CT data reconstructed on 3D workstations. Post-operatively all patients were evaluated radiologically at hospital discharge, at 6, 12, 18 and 24months, and annually thereafter.

The Proximal Fixation Strength of Modern EVAR Grafts in a Short Aneurysm Neck. An In Vitro Study

2010-02-01

Objectives: The study aims to measure the strength of the proximal fixation of endografts in short and long necks. Design: Three types of endografts were compared: Gore Excluder®, Vascutek Anaconda® and Medtronic Endurant®.

The Influence of Different Types of Stent Grafts on Aneurysm Neck Dynamics after Endovascular Aneurysm Repair

2010-02-01

Objective: Dynamic imaging provides insight into aortic shape changes throughout the cardiac cycle. These changes may be important for proximal aortic stent graft fixation, sealing and durability. The objective of this study is to analyse the influence of different types of stent grafts on dynamic changes of the aneurysm neck.

Diabetes and the Abdominal Aortic Aneurysm

S. Shantikumar, R. Ajjan, K.E. Porter, D.J.A. Scott — 2010-02-01

Objective: The aim of this review is to delineate the association between abdominal aortic aneurysms (AAAs) and diabetes mellitus. Mechanisms for the underlying association are then discussed.

Poor Inter-observer Agreement on the TASC II Classification of Femoropopliteal Lesions

2010-02-01

Objectives: This study aims to evaluate the reproducibility of femoropopliteal TASC II classification and to analyse the influence of an educational intervention on inter-observer agreement.

Modified Ankle–brachial Index Detects More Patients at Risk in a Finnish Primary Health Care

N.K.J. Oksala, J. Viljamaa, E. Saimanen, M. Venermo, ATTAC study group — 2010-02-01

Objectives: Despite peripheral arterial disease (PAD), defined as ankle–brachial index (ABI)≤0.9, being an independent predictor of cardiovascular morbidity and mortality, it is rarely used in the primary care. Various definitions for PAD (i.e., ABI≤0.9 or ABI≤0.95) exist. In addition, a modified ABI (ABImod) using the lowest ankle pressure improves identification of patients at risk. The prevalence of PAD in primary care and association of different ABI calculations with atherosclerotic disease burden is not known.

The Vascular Repair of Aortic Transection Secondary to Trauma: A Safe and Effective Method in Patients with Complicated Injuries

2010-02-01

Objectives: Historically thoracic aortic rupture secondary to trauma was treated with cardiopulmonary bypass and open surgery. With the advent of endovascular grafting, physicians have the ability to reconstruct the thoracic aortic transection using a less invasive technique. In this study, we examine our experience with stent graft repair of thoracic transections secondary to trauma.

Trends and Outcomes of Endovascular and Open Treatment for Traumatic Thoracic Aortic Injury

Frederik H. Jonker, Jeanine K. Giacovelli, Bart E. Muhs, Jeffrey Indes — 2010-02-01

Objectives: Data supporting endovascular thoracic aortic repair (TEVAR) to reduce morbidity and mortality for traumatic thoracic aortic injury (TTAI) is limited to case series and meta-analyses. In this study, we evaluated the trends and outcomes of open surgery and TEVAR for TTAI in New York State.

Propensity Score Analysis Validates Findings of the VALOR Trial (TEVAR For Degenerative Thoracic Aneurysms)

2010-02-01

Introduction: The VALOR trial reported superior outcomes of the Talent thoracic endovascular aneurysm repair (TEVAR) compared with surgery for descending thoracic aneurysms (JVS 2008;48:546-54). Data from 195 prospective TEVAR patients were compared with 189 historical surgical controls (OG) included into the trial after completion of TEVAR enrollment. Such retrospective comparisons are biased by differences among TEVAR vs OG. This applied study propensity score (PS) analysis, which reduces bias by participant matching, to validate findings of the VALOR trial.

Outcome of Endovascular Abdominal Aortic Aneurysm Repair in Octogenarians and Nonagenarians: Single-Center Experience

2010-02-01

Objective: 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 ≥80 years of age.

Preoperative Anatomic Variables Are Predictive of Persistent Type 2 Endoleak after EVAR

2010-02-01

Objectives: Persistent type 2 endoleaks (PT2) present ≥6 months after endovascular aneurysm repair (EVAR) are associated with adverse outcomes. This study evaluated the preoperative risk factors and natural history of PT2 to define a population at high-risk.

Does Renal Transplantation Improve Endovascular Interventional Outcomes for Patients with Chronic Renal Insufficiency?

2010-02-01

Introduction: It has been suggested that preemptive renal transplantation can reduce the incidence and severity of peripheral vascular disease (PVD) and improve limb salvage. Immunosuppressed transplant patients may have a decreased incidence of in-stent restenosis. This study compared limb salvage and patency rates after endovascular interventions among patients with chronic renal insufficiency (CRI), functional and failed renal transplants (RT), and normal renal (NR) function.

Repeat Angioplasty and Stenting for Femoropopliteal Occlusive Disease: Factors Affecting Outcomes of the Second-Time Endovascular Intervention

William P. Robinson, Louis L. Nguyen, Richard Bafford, Michael Belkin — 2010-02-01

Introduction: Repeat percutaneous interventions for femoropopliteal occlusive disease are common, but the outcomes are poorly understood. We sought to determine the results of second-time femoropopliteal percutaneous transluminal angioplasty/stenting (SPTAS) and identify factors associated with outcome.

Venous Stenting for Lower Extremity Stasis Symptoms

2010-02-01

Introduction: In a small subset of patients presenting with severe venous stasis disease, we have been unable to identify the sources of reflux with standard duplex imaging of the superficial, deep, and perforating veins. Recently, we have been examining the iliac veins with intravascular ultrasound (IVUS) imaging and venography to identify stenotic lesions and reviewed our findings with this technique.

Aggressive Treatment of Idiopathic Axillosubclavian Vein Thrombosis (ASVT) Provides Excellent Long-Term Function

2010-02-01

Introduction: A multidisciplinary approach has evolved as the common therapy for axillosubclavian vein thrombosis (ASVT). Although much attention has been devoted toward treatment paradigms, little has been directed toward functional outcomes. This study documented long-term functional outcomes in patients treated for ASVT.

Endovascular Management (Percutaneous Transluminal Angioplasty) of Patients with Critical Limb Ischemia: Long-Term Results

2010-02-01

Introduction: Although percutaneous transluminal angioplasty (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), where anatomic disease is more extensive, remains unclear. The present study defined late (5-year) clinical and patency data for PTA in CLI.

Surgical Repair of Complex Renal Artery Aneurysms: Favorable Outcomes with In Situ Techniques

William P. Robinson, Richard Bafford, Michael Belkin, Mathew T. Menard — 2010-02-01

Introduction: The optimal method of operative management of complex branch renal artery aneurysms remains unclear, with recent reports predominantly espousing ex vivo repair. We sought to determine the long-term outcome of renal artery aneurysm (RAA) repair performed with in situ techniques.

Outcomes of Symptomatic Abdominal Aortic Aneurysm Repair: A Multicenter Review from the Vascular Surgery Study Group of Northern New England (VSGNNE)

2010-02-01

Objective: Operative mortality of patients undergoing symptomatic abdominal aortic aneurysm (AAA) repair has been reported to be 6% to 30% during the past 25 years. We sought to describe the contemporary outcomes of patients undergoing repair of symptomatic AAA using a multicenter, regional database.

Volume Outcome Relationship for Endovascular Aortic Aneurysm Repair and Open Abdominal Aortic Aneurysm Repair in United States Medicare Patients

2010-02-01

Introduction: Mortality after open abdominal aortic aneurysm (AAA) repair is inversely proportional to procedure volume. It is unclear if this is true for endovascular AAA repair (EVAR) or if EVAR volume predicts outcome with open repair or vice versa. This will become important as centers shift volume to EVAR.

Accuracy of Cardiac Risk Prediction Models in Patients Undergoing Open Abdominal Aortic Aneurysm Repair or Lower Extremity Bypass

2010-02-01

Objective: The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We tested the accuracy of the RCRI in vascular surgery patients compared with a specific model developed from these patients.

Preoperative Statin Therapy Is Associated with Improved Outcomes and Lower Resource Utilization in Patients Undergoing Open or Endovascular Aortic Aneurysm Repair

2010-02-01

Introduction: Evidence suggests inhibition of cholesterol synthesis with statins has a beneficial effect on atherosclerotic plaque in a variety of vascular diseases. This study hypothesized that preoperative statin therapy would have a protective effect on patients undergoing elective abdominal aortic aneurysm (AAA) repair owing to the pleiotropic effect of these agents.

Despite Higher Utilization of Carotid Angioplasty and Stenting (CAS) in 2006, Postprocedure Stroke, Mortality Rates, Hospital Charges, and Discharges to Nursing Skilled Facilities Remain Higher for CAS than for Carotid Endarterectomy Compared with 2005

2010-02-01

Objective: This study compared, at the national level, trends in utilization, mortality, and stroke of carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) during 2005-2006.

Long-Term Outcome of Carotid Endarterectomy with Bovine Pericardial Patch Closure: A Comparison to Dacron Patch and Primary Closure

Karen J. Ho, Matthew T. Menard — 2010-02-01

Objectives: Bovine pericardial patches (BPP) are increasingly used during femoral and carotid endarterectomies (CEA), and owing to handling and sonographic properties, have become our patch material of choice in recent years. However, the long-term performance of this material compared with other CEA closure strategies remains poorly defined. We sought to determine how infection and bleeding complications after CEA performed with BPP compared with CEA performed with Dacron patches or primary closure (PC).

Stroke and Death after Carotid Endarterectomy and Carotid Artery Stenting with and without Coronary Artery Bypass

2010-02-01

Objectives: By Centers for Medicare and Medicaid Services (CMS), carotid artery stenting (CAS) patients are high surgical risk. We evaluated mortality and stroke after CEA and CAS combined with and without coronary artery bypass grafting/valve surgery (CABG/V) and adjusted for medical high-risk criteria.

Novel Implantable Vein Graft Contrast Yields Enhanced Outer Wall Definition in Magnetic Resonance Imaging

2010-02-01

Introduction: Emerging data support a role for negative wall remodeling in the failure of vascular interventions such as vein grafts, yet clinicians and researchers currently lack the ability to temporally and efficiently interrogate the adventitial surface topography and total vascular wall anatomy in vivo. Our long-term goal is the development of an implantable contrast material immobilized on the vein conduit outer surface ex vivo at the time of operation that will allow high-throughput and spatial resolution vascular wall imaging in vivo longitudinally. We hypothesized that commercially available iron (Fe) magnetic nanoparticles can be covalently immobilized onto the human vein graft wall and subsequently enable delineation of the adventitia with magnetic resonance imaging (MRI).

A Novel Cellular Model of Vein Graft Adaptation

2010-02-01

Introduction: Vein graft adaptation (VGA) is characterized by thickening of the vein wall, a complex process involving cell proliferation and migration. We have previously shown that VGA is also characterized by loss of the venous determinant Eph-B4. We developed an in vitro model to study molecular mechanisms that mediate VGA.

Divergent Systemic and Local Inflammatory Response to Hind Limb Demand Ischemia in Wild-Type and Hypercholesterolemic Mice

2010-02-01

Introduction: In patients with peripheral vascular disease, claudication is a frequent symptom related to skeletal muscle demand ischemia. These studies were designed to compare and contrast the influence of hypercholesterolemia on the local and systemic inflammatory response to demand ischemia (ie, exercise) in a murine model of vascular occlusive disease.

Long-Term Results of Open Versus Endovascular Revascularization of Superficial Femoral Artery Occlusive Disease: A Case-Control Series

2010-02-01

Introduction: We performed a case-control comparison of long-term results of femoral-popliteal bypass and superficial femoral artery (SFA) endovascular interventions to examine characteristics of patients and procedures to optimize results.

Pushing the Limits of Endovascular Intervention: Short-Term Outcomes for TransAtlantic Inter-Society Consensus II D Lesions

2010-02-01

Introduction: Advances in endovascular techniques have provided new options in the treatment of complex infrainguinal occlusive disease. This study evaluated outcomes of endovascular interventions on TransAtlantic Inter-Society Consensus (TASC II) D femoropopliteal lesions.

Standardized Techniques for Percutaneous Treatment of Superficial Femoral Artery-Popliteal TransAtlantic Inter-Society Consensus C and D Lesions Improve Outcomes: Midterm Analysis of a Prospective Intent-to-Treat Study

2010-02-01

Purpose: To better understand the implications of the percutaneous superficial femoral artery (SFA)-popliteal procedure techniques, we compared the patency of treating TransAtlantic Inter-Society Consensus (TASC) C and D lesions by using a standardized vs a nonstandardized approach.

Editorial Board

2010-02-01

Information for authors

Anton N. Sidawy, Bruce A. Perler — 2010-02-01

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

2010-02-01

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, 24th 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

2010-02-01

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