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Thoracic Aortic Transection Treated by Thoracic Endovascular Aortic Repair: Predictors of Survival

Ryan, M., Valazquez, O., Martinez, E., Patel, S., Parodi, J., Karmacharya, J. — Mon, 16 Nov 2009 02:52:29 PST

Background: We reviewed all patients presenting to our institution with a traumatic thoracic aortic injury (TTAI) between January 2006 and May 2007. Age, gender, injury severity score (ISS), location of injuries, surgical intervention, and length of stay were assessed to determine what characteristics might be predictive of survival. Of the 56 patients who were identified, 23 (41%) were dead on arrival, 15 (20%) died on that admission, and 18 (32%) survived to discharge. Injury severity score was elevated in mortalities (57) compared to survivors (34). Penetrating and blunt aortic injuries had 89% and 58% mortality rates, respectively. Female gender was associated with increased survival (P = .032), as was receiving surgical intervention (P = .03). Patients with a prolonged ICU stay demonstrated increased survival. All eight patients who received thoracic endovascular aortic repair survived to discharge. Injury severity score, mechanism, thoracic endovascular aortic repair (TEVAR), female gender, and surgical treatment were associated with survival after TTAI.

Iatrogenic Pseudoaneurysm of the Superior Gluteal Artery Presenting as Pelvic Mass With Foot Drop and Sciatica: Case Report and Review of Literature

Ge, P. S., Ng, G., Ishaque, B. M., Gelabert, H., Virgilio, C. d. — Mon, 16 Nov 2009 02:52:28 PST

We report an unusual case of a pseudoaneurysm of the superior gluteal artery as a complication of bone marrow biopsy. A 51-year-old man presented with sciatic pain and foot drop after undergoing bone marrow biopsy and was initially diagnosed as having degenerative disc disease based on his past medical history. Pelvic magnetic resonance imaging (MRI) revealed a large heterogeneous mass suggestive of a neurogenic tumor, but pulsatile blood was instead encountered during computed tomography (CT)-guided needle biopsy. Subsequent workup established the diagnosis of a superior gluteal artery pseudoaneurysm, which was treated with coil embolization, followed by surgical evacuation of the hematoma, which relieved his sciatic pain. However, the patient continues to have a persistent foot drop. Gluteal artery pseudoaneurysms are exceedingly uncommon but should be considered in the workup of a patient with gluteal pain or sciatic nerve palsy following trauma or medical procedures in the gluteal region.

Agenesis of Bilateral Internal Carotid Artery Associated With Basilar Artery Fenestration Mimicking Intra-Arterial Thrombus: A Case Report

Yim, N. Y., Ha, H.-I., Park, J.-H., Moon, Y.-J., Yoon, W., Kim, J.-K. — Mon, 16 Nov 2009 02:52:28 PST

Bilateral internal caroid artery agenesis is a very rare congenital anomaly, which may be accompanied by various types of associated vascular abnormalities, included intracranial aneurysms or dolichoectatic change of posterior circulation. In this article, we present unique, and to the best of our knowledge, the first case of bilateral internal carotid agenesis associated with basilar artery fenestration, which resembles intra-arterial floating thrombus.

Stent Graft Repair of Iatrogenic Femoral Arteriovenous Fistula: An Useful Therapeutic Approach in a Hostile Groin

De Martino, R. R., Nolan, B. W., Powell, R. J., Walsh, D. B., Stone, D. H. — Mon, 16 Nov 2009 02:52:27 PST

The incidence of iatrogenic femoral arteriovenous fistulas (IFAVF) has increased in contemporary practice. We herein report the case of a 55-year-old obese woman with significant surgical comorbidities who sustained an IFAVF between the superficial femoral artery (SFA) and the femoral vein. Given her substantial risk factors, she was treated with a SFA stent-graft (iCast 6 x 22 mm) using a contralateral endovascular approach. She remains asymptomatic at 15 months with ongoing resolution of the AVF. This report highlights the utility of stent-graft repair of an IFAVF in high surgical risk patients or in those with "hostile" anatomy.

Endovascular Repair of Aorto-Bi-Iliac Aneurysm

Paravastu, S., Farquharson, F., Serracino-Inglott, F. — Mon, 16 Nov 2009 02:52:29 PST

Iliac bifurcated devices (IBDs) are used in the endovascular treatment of aorto-iliac and common iliac artery aneurysms to preserve the flow to at least one internal iliac artery thereby decreasing the risk of pelvic ischemic complications. We report the use of IBDs in preserving both the internal iliac arteries.

A Report of Spinal Cord Ischemia Following Endovascular Aneurysm Repair of an Aneurysm With a Large Thrombus Burden and Complex Iliac Anatomy

Lioupis, C., Tyrrell, M., Valenti, D. — Mon, 16 Nov 2009 02:52:28 PST

We report a case of paraplegia occurring after an elective endovascular aneurysm repair (EVAR) that was reversed by cerebrospinal fluid (CSF) drainage. This case report highlights the reality that the endovascular management of abdominal aortic aneurysms (AAAs) with large volumes of mural thrombus and complex iliac anatomy can be complicated by spinal cord ischemia (SCI). The presumed mechanism of SCI is dissemination of atherosclerotic material during protracted catheter and wire manipulations. Embolization of internal iliac arteries (IIAs), profunda femoral arteries, and possibly other arterial networks may explain the delayed presentation. The complex iliac anatomy necessitating covering of one and reconstruction of the other hypogastric artery and the prolonged operative time may be 2 other contributing factors. The prompt CSF drainage may reverse the neurologic deficit.

Diagnosis and Management of Aortic Mycotic Aneurysms

Leon, L. R., Mills, J. L. — Mon, 16 Nov 2009 02:52:27 PST

We reviewed all papers most recently reported in the literature (January-December 2008) with regard to infected arterial aneurysms (IAAs) affecting the aorta. Most of the recently reported knowledge is limited to case reports and small series of aortic mycotic aneurysms. Most patients are elderly men and have comorbidities at presentation. Aneurysms were most commonly associated to Salmonella and Staphylococcus. However, several cases of aortic IAAs caused by atypical pathogens were also reported, likely due to an increase in immunosuppressive illnesses, increased life expectancy, improved diagnostic methods, and increasing medical awareness. Open surgical therapy of IAAs remains the gold standard. Some have reported successful outcomes with endovascular methodologies for patients medically compromised or for particular challenging clinical or anatomical scenarios. However, at this time, conclusive evidence is lacking and it should be in general considered a bridge to open repair. The latter should be planned at the earliest possible, when medically permissible.

Early Inflammatory Response in Patients With Ruptured Abdominal Aortic Aneurysm

Wallinder, J., Skagius, E., Bergqvist, D., Henriksson, A. E. — Mon, 16 Nov 2009 02:52:28 PST

Multiorgan failure is the main cause of death in patients operated for ruptured abdominal aortic aneurysm (rAAA). The systemic inflammatory response plays a central role in the generation and maintenance of multiorgan dysfunction. The aim of the current study was to investigate the inflammatory response preoperatively in patients with ruptured and nonruptured AAA in relation to the clinical outcome. A total of 95 patients about to undergo repair of AAA (43 ruptured with shock, 12 ruptured without shock, and 40 elective) and 41 controls without aneurysm matched by age, gender, and smoking habits were investigated by inflammatory markers. There were significantly higher levels of interleukin 6 (IL-6; proinflammatory cytokine) and IL-10 (anti-inflammatory cytokine) in patients operated for ruptured compared to nonruptured AAA. In conclusion, the current data indicate that rupture of an AAA activates the inflammatory system with a compensatory anti-inflammatory response.

A Composite Approach to Thoracic Aortic Stent Grafting

Wed, 28 Oct 2009 04:14:55 PDT

Thoracic endovascular aortic repair has become the preferred modality for the treatment of diverse aortic pathologies of the thoracic aorta. This report is the first to describe the use of 2 different devices for successful exclusion of a dissecting thoracic aneurysm.

Crossing an Ultracritical Carotid Stenosis for Carotid Angioplasty

Dahn, M., Cheema, M., Bozeman, P., Divinagracia, T. — Wed, 14 Oct 2009 03:17:13 PDT

Carotid angioplasty requires early placement of a cerebral protection device in an effort to minimize cerebral embolization during the conduct of the subsequent angioplasty and stenting procedure. In patients who exhibit a very critical internal carotid artery (ICA) stenosis (~99%), initial passage of the lesion may not be possible with a standard 0.014-inch wire system. In this report, the authors describe an approach using a 0.012-inch hydrophilic system to overcome this technical obstacle.

Prediction of Major Adverse Cardiac Events in Vascular Surgery: Are Cardiac Risk Scores of Any Practical Value?

Parmar, C D, Torella, F — Wed, 14 Oct 2009 03:17:13 PDT

Background: Disease-specific preoperative scoring systems are often used to predict postoperative cardiac complications. We retrospectively evaluated the accuracy of 2 cardiac risk scores in the prediction of major adverse cardiac events (MACE) after vascular surgery.

Methods: Consecutive procedures were "scored" according to the Revised Cardiac Risk Index (RCRI) and the Eagle criteria. Two "generic" risk scoring systems, ASA (American Society of Anesthesiology) grade and the physiology Portsmouth POSSUM (P-POSSUM) score, were also documented for comparison.

Results: After 344 surgical procedures, 18 patients suffered a MACE (5.2%; 95% CI = 2.8-7.58-4 fatal). The RCRI (AUC 95% CI = 0.68 [0.57-0.83], P = .009) and the Eagle criteria (AUC 95% CI = 0.73 [0.57-0.8], P = .001) were no better than P-POSSUM (AUC 95% CI = 0.82 [0.73-0.91], P < .001) and ASA grade (AUC 95% CI = 0.67 (0.56-0.78), P = 0.016) in predicting MACE. Of the variables included in the 2 cardiac scoring systems, only age and history of ischemic heart disease were associated with MACE in our patients.

Conclusion: Cardiac risk scores were no better than generic risk scoring systems in predicting MACE. Poor performance may be due to differences between our patient population and those in which the scores were developed and to improved perioperative management of cardiac risk.

Initial Results of Concomitant Cryoplasty After Remote Endarterectomy of the Superficial Femoral Artery: A Feasibility Study (Cryoplasty Following Remote Endarterectomy)

Wed, 14 Oct 2009 03:17:13 PDT

Objective:Remote endarterectomy is a less invasive technique compared with supragenicular bypass surgery for superficial femoral artery (SFA) occlusive disease. Early restenosis remains one of the drawbacks of this procedure. To prevent restenosis following remote endarterectomy, concomitant cryoplasty of the desobstruct SFA was introduced. Methods: A prospective cohort study was initiated with 17 patients treated with cryoplasty of the SFA after remote endarterectomy. Indications for surgery were claudication (n = 12), rest pain (n = 3), or tissue loss (n = 2). Results: There were no technical failures. The Kaplan-Meier estimate of the primary and assisted primary patency rate after 1 year of follow-up was 74%. Secondary patency was 89%. Limb salvage was 100%. No aneurysmal degeneration and no other adverse events occurred during the follow-up. Conclusions: This pilot study showed that cryoplasty after remote SFA endarterectomy is a safe procedure, with promising patency rates.

Percutaneous Endovascular Management of Occluded HeRO Dialysis Access Device

Vasquez, J. C., DeLaRosa, J., Leon, J. J., Rahim, N., Rahim, F. — Wed, 14 Oct 2009 03:17:12 PDT

The Hemodialysis Reliable Outflow (HeRO) device is a novel alternative for dialysis access in patients with no suitable veins in the upper extremities. We placed a HeRO device in a 67-year-old woman with end-stage renal disease and 2 months later, it was being used for hemodialysis. After 1 month of uneventful use, the device thrombosed and it was rescued with a percutaneous endovascular approach. The device remains patent 6 months after the intervention.

Management of a Chronic Carotid Artery Pseudoaneurysm

Baker, A. C., Arko, F. R., Zarins, C. K., Lee, E. S. — Wed, 14 Oct 2009 03:17:12 PDT

An 82-year-old female with a history of right carotid endarterectomy with patch closure 12 years prior presents with a pulsatile right neck mass with skin erosion and bleeding. The patient had been previously evaluated but refused the surgical intervention because a median sternotomy was recommended to obtain adequate proximal control. Her aneurysm was successfully repaired using a combination of open and endovascular method. The repair was performed through a right-hand side anterior sternocleidomastoid neck incision, and proximal vascular control was obtained with an 8.5-mm balloon positioned under fluoroscopic guidance via a femoral puncture.

Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm in a Patient With Unfavorable Anatomy

Bellosta, R., Luzzani, L., Carugati, C., Cossu, L., Sarcina, A. — Wed, 14 Oct 2009 03:17:12 PDT

Endovascular repair of an abdominal aortic aneurysm (AAA) offers hope of improved outcomes in patients presenting with acute rupture. However, a high proportion of such patients have unfavorable proximal neck anatomy and are not suitable for treatment with conventional endografts. In this case report, the authors describe a successful endovascular repair of a ruptured AAA with very short and angulated proximal neck.

Vascular Wall Invasion in Neurofibromatosis-Induced Aortic Rupture

Wed, 14 Oct 2009 03:17:11 PDT

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disease primarily characterized by cutaneous café au lait macules, benign neurofibromas, and iris hamartomas. A spectrum of vascular abnormalities is associated with NF-1. We present a case of a 49-year-old female with NF-1 and spontaneous rupture of the infrarenal aorta caused by invasion of a neurofibroma and treated with endovascular stent grafting.

Effect of Saphenous Vein Diameter on Closure Rate With ClosureFAST Radiofrequency Catheter

Calcagno, D., Rossi, J. A., Ha, C. — Wed, 14 Oct 2009 03:17:11 PDT

Purpose: Radiofrequency ablation (RFA) of veins >12 mm in diameter has been a controversial subject since the first-generation device was submitted for Food and Drug Administration (FDA) approval. Veins >12 mm were excluded in the initial study. Many insurance carriers used >12 mm size as reason to not approve the procedure. As the concept of tumescent anesthesia was better communicated, RFA was used for large veins. The 12-mm size limit was not used in the studies for the newer ClosureFAST catheter approval, yet remains in force with some insurance companies. Our objective was to determine whether vein diameter >12 mm had effect on closure rates with the ClosureFAST catheter.

Methods: ClosureFAST RFA was used to eliminate saphenous reflux in consecutive cases in 1 center. Retrospective analysis was performed on prospectively gathered data. Veins were divided into ≤12 mm diameter (group A) or >12 mm diameter (group B). Duplex scans were scheduled for 2 to 5 days and 6 months postprocedure.

Results: A total of 338 great and small saphenous veins were treated, 246 saphenous veins in group A (mean 8 ± 2 mm) and 96 in group B (mean 17 ± 4 mm). Early duplex showed complete closure in 231 veins in group A (94%) and 92 veins in group B (96%; NS). The remaining veins showed partial closure with none showing retrograde flow. Six-month duplex scans were completed in 155 veins. Complete closure was seen in 110 veins in group A (98%) and 43 veins in group B (100%; NS). All veins partially open on early scan had closed by 6 months. The 2 veins open at 6 months in group A were closed on initial scan.

Conclusions: Vein diameter >12 mm had no effect on closure rate with the ClosureFAST catheter.

Unilateral Lower Limb Paralysis After Aortobifemoral Bypass Graft for Ruptured Abdominal Aortic Aneurysm: A Case Report

Deylgat, B., Wallaert, P., Smul, G. D., Lysebeth, L. V., Ceuppens, H. — Wed, 14 Oct 2009 03:17:11 PDT

An 81-year-old man underwent an aortobifemoral bypass graft because of a ruptured abdominal aortic aneurysm. His postoperative recovery was complicated by unilateral lower limb paralysis caused by perioperative ischemia of the lumbosacral plexus. Ischemic lumbosacral plexopathy is an uncommon complication after infrarenal aortic surgery with serious morbidity. Despite a good surgical technique and knowledge of the vascularization of the spinal cord, its occurrence remains unpredictable.

Finite Element Model of the Patched Human Carotid

Wed, 14 Oct 2009 03:17:10 PDT

Introduction: The hemodynamic effects of carotid artery patching are not well known. Our objective was to develop a fluid-solid finite element model of the endarterectomized and patched carotid artery.

Methods: Inelastic materials parameters were determined from studies of 8 cadaveric carotids. Blood flow characteristics were based on intraoperative data from a patient undergoing endarterectomy. Wall shear stress, cyclic strain and effective stress were computed as hemodynamic parameters with known association with endothelial injury, neointimal hyperplasia abd atherogenesis.

Results: Low wall shear stress, high cyclic strain and high effective stress were identified diffusely in the carotid bulb, at the margins around the patch and in the flow divider.

Conclusion: Endarterectomy and Polytetrafluoroethylene patching produce considerable abnormalities in the hemodynamics of the repaired carotid. Advanced mechanical modeling can be used to evaluate different carotid revascularization approaches to obtain optimized biomechanical and hemodynamic results for the care of patients with carotid bifurcation disease.

Staged Approach for Surgical Management of External Iliac Vein Aneurysm Associated With Traumatic Femoral Arteriovenous Fistula

Vasquez, J. C., Montesinos, E., DeLaRosa, J., Leon, J. J. — Wed, 14 Oct 2009 03:17:10 PDT

Aneurysms of the iliac vein are rare. They can occur in association with arteriovenous fistulae located elsewhere. Here, we present a 30-year-old man who developed a large left external iliac vein aneurysm in association with a chronic traumatic arteriovenous fistula in the left thigh. Less than 25 cases of iliac vein aneurysms have been reported in the last 40 years. The presentation and treatment of this condition has been heterogeneous. We suggest that adequate surgical treatment can be offered in a staged approach: aneurysm resection with reconstruction should be done first, followed by closure of the arteriovenous fistula 6 months later.

Hybrid Repair of Isolated Internal Iliac Artery Aneurysm

Chandra, A., Kansal, N. — Wed, 14 Oct 2009 03:17:10 PDT

Isolated aneurysms of the internal iliac artery (IIIAA) represent a rare pathology. The application of endovascular therapy has been shown to reduce both mortality and blood loss. We present a case of an isolated left internal iliac artery aneurysm treated with a hybrid approach. A 92-year-old male was found to have an asymptomatic 4.6-cm aneurysm of the left internal iliac artery. He underwent coil embolization of 3 branch outflow arteries of the aneurysm. With completion angiography confirming no distal flow, we performed open ligation of the left internal iliac artery at its origin with minimal blood loss. The patient experienced no pelvic ischemia symptoms following repair. Computed tomography (CT) scan confirmed aneurysm exclusion at 4-year follow-up. The hybrid approach to IIIAA in the nonagenarian population is a viable alternative and may confer significant improvements in outcomes and blood loss.

Complete Endograft Collapse 91/2 Years Following Endograft Repair of an Abdominal Aortic Aneurysm

McCready, R. A., Bryant, M. A., Divelbiss, J. L., Phillips, J. L. — Wed, 14 Oct 2009 03:17:12 PDT

Endografts are a common method of treating abdominal aortic aneurysms (AAA) because of the short-term benefits of endovascular aneurysm repair (EVAR). However, the short-term benefits of endovascular repair must be balanced against long-term complications, such as the need for conversion to open repair, device migration, persistent or de novo endoleaks, and most concerning the potential for subsequent rupture of the aneurysm. Lifelong postimplantation surveillance is mandatory because the incidence of some complications increases over time. This report describes our recent experience in a patient in whom complete endograft collapse was discovered 91/2 years following EVAR necessitating conversion to open repair.

The Protective Effect of Oxygenated Perfluorocarbons (PFCs) on Intestinal Ischemia Reperfusion Injury (I/R) in Rabbits

Thu, 27 Aug 2009 05:38:39 PDT

Objective: To evaluate the effect of intraluminal administration of oxygenated perfluorocarbons (PFCs) on small intestine's viability in an experimental model of acute ischemia-reperfusion (I/R). Methods: Twenty rabbits were divided in four groups: sham-operated controls (group A), acute I/R (group B), acute I/R plus infusion of PFCs 30 min before ischemia (group C), and acute I/R plus infusion of PFCs 30 min before reperfusion (group D). Malondialdehyde (MDA) tissue levels and d-lactate blood samples were taken. All tissue sections were examined under light microscope. Results: Mean MDA levels in group A: 1.79 ± 0.97 at 0 min, 2.25 ± 1.76 at 120 min and 3.70 ± 1.76 nmols/g at 180 min. Group B: 2.60 ± 0.58 at 0 min, 4.20 ± 0.58 at 120 min and 5.48 ± 2.01 at 180 min. Group C: 1.54 ± 0.85 at 0 min, 1.14 ± 0.37 at 120 min and 0.59 ± 0.35 at 180 min. Group D: 2.12 ± 0.62 at 0 min, 3.97 ± 0.70 at 120 min and 2.32 ± 0.37 at 180 min (p < 0.05). Mean d-lactate levels in group A: at 0 min 36.45 ± 1.99, at 120 min 39.10 ± 2.37 and at 180 min 40.05 ± 2.13 mg/dl. Group B: 61.23 ± 11.03 at 0 min, 74.84 ± 10.70 at 120 min and 89.90 ± 9.29 at 180 min. Group C: at 0 min 51.05 ± 10.36, at 120 min 56.07 ± 11.27 and at 180 min 57.20 ± 11.19. Group D: 64.36 ± 5.26 at 0 min, 72.55 ± 7.19 at 120 min and 77.02 ± 9.41 at 180 min (p < 0.05). Histopathological analysis indicated a significant improvement in the groups of oxygenated PFCs compared with I/R group. Conclusion: Intraluminal administration of oxygenated PFCs seems that protect the intestine from the I/R injury.

Symptomatic 7-cm Abdominal Aortic Aneurysm in an Otherwise Healthy 31-Year-Old Woman

Moos, J. M., Rowell, S., Dawson, D. — Wed, 29 Jul 2009 02:24:49 PDT

Abdominal aortic aneurysms are rare in young women. We report the case of a 31-year-old woman who underwent open surgical repair of a symptomatic 7-cm abdominal aortic aneurysm (AAA). The patient had no identifiable AAA risk factors. Laboratory and pathological analyses demonstrated a nonspecific inflammatory component.

Primary Aortoenteric Fistula and Endovascular Repair

Jayarajan, S., Napolitano, L. M., Rectenwald, J. E., Upchurch, G. R. — Wed, 29 Jul 2009 02:25:00 PDT

Primary aortoenteric fistulae are difficult conditions to diagnose and manage. A 35-year-old male developed massive upper gastrointestinal hemorrhage due to a primary aortoduodenal fistula. Previous radiation therapy and retroperitoneal lymph node dissection for germ cell cancer with resultant dense retroperitoneal fibrosis made open aortic repair impossible. Endovascular balloon occlusion of the aorta and stent graft repair of the primary aortoduodenal fistula was performed. At 1-year follow-up, there is no clinical or radiographic evidence of stent-graft infection. Endovascular techniques and repair are important approaches to consider during the management of complicated primary aortoenteric fistulae when open surgical repair is not feasible.

Aortic Arch Resection and Ligation of the Descending Thoracic Aorta to Manage a Ruptured Thoracoabdominal Aneurysm

Weiss, A., Di Luozzo, G., Etz, C., Griepp, R. — Wed, 29 Jul 2009 02:24:44 PDT

Thoracoabdominal aortic aneurysms (TAAAs) are treated traditionally with open surgical repair; however, selective, high-risk patients can be evaluated for an endovascular approach. If the TAAA is complicated by the presence of aortic rupture, open surgical intervention is conventionally the course of action. However, unlike the primary operation, reoperations of TAAA might necessitate less conventional approaches. We report a patient with a previously repaired, ruptured, acute type B aortic dissection, who presents with a contained rupture of a TAAA.

Carotid Artery Stenting for Stenosis Following Cervical Radiotherapy: Report of Early Failure With Associated Stent Fracture

Ross, C. B., Khoobehi, A., Irwin, C. L., Dattilo, J. B., Naslund, T. C. — Wed, 29 Jul 2009 02:24:57 PDT

Experience with carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CE) for management of carotid stenosis continues to evolve. We report the case of a 64-year-old man who was treated with bilateral CAS for stenoses, which developed 7 years following thyroidectomy, neck dissection, and radiotherapy. Although long considered an ideal alternative to CE in this clinical setting, CAS in this case was complicated by multiple episodes of recurrent stenosis in his left carotid, managed by balloon angioplasty. Severe, early recurrence in his right carotid associated with a type III stent fracture was managed by CE. Close surveillance and intervention prevented neurologic morbidity. This case, combined with emerging published experience, argues for reappraisal of the general consensus that CAS is an ideal alternative to CE for radiotherapy-associated carotid stenoses.

What Is Wrong in the Cava? A Rare Cause of Deep Vein Thrombosis

Deylgat, B., Holsbeeck, B. V., Gellens, P. — Wed, 29 Jul 2009 02:24:58 PDT

When using cement in a hip arthroplasty, high intramedullary pressures are generated. This may lead to several complications, ranging from local extravasation to systemic complications such as the implantation syndrome. Until now, venous migration of cement after hip arthroplasty has never been associated with morbidity or mortality. We present a case in which cement pressurization lead to migration of cement up to the level of the inferior vena cava with subsequent deep vein thrombosis.

Carotid Artery Pseudoaneurysm After Carotid Endarterectomy: Case Series and a Review of the Literature

Abdelhamid, M. F., Wall, M., Vohra, R. — Wed, 29 Jul 2009 02:24:49 PDT

Background: Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare complication with incidence less than 1%. There is a potential for rupture, embolization, thrombosis or compression of cranial nerves. Objective: We reviewed our experience and compare it to the literature to raise awareness of this rare though serious condition. It is crucial to treat these patients early to avoid the hazardous consequences. Methods: A review of the case records of patients who had CEA at University Hospital Birmingham (UHB) NHS Foundation Trust from 1990-2007, was undertaken. Information of patients including their aetiology, presenting features, treatment and results was collected. The English-language literature was searched using PubMed database for post CEA pseudoaneurysm. Results: Five patients developed post CEA PA. This represents 0.4% of the 1200 CEA performed at our hospital in the last 18 years. The timing of their presentation varied from three days to eight months after the original operation. All had patch reconstruction after CEA. Patches were intact at exploration of the PAs. There was one death and one stroke. The literature revealed 154 carotid PAs after CEA and two cases following carotid stenting 52 of these cases had infected PA. Patients with synthetic patches have the least incidence of infection. More than 80% had open surgery and 9% had endovascular repair. Conclusion: Post CEA surveillance is necessary to detect patients with PA early. Factors that favour infection must be avoided. Endovascular repair of carotid PA should be encouraged in specialised centres.

Evaluation of Serum Matrix Metalloproteinases as Biomarkers for Detection of Neurological Symptoms in Carotid Artery Disease

Heider, P., Pelisek, J., Poppert, H., Eckstein, H.-H. — Wed, 29 Jul 2009 02:24:48 PDT

Objective: Relevant soluble matrix metalloproteinases (MMPs), their inhibitors, tissue inhibitor of metalloproteinases (TIMPs), and serological factors were analyzed as possible biomarkers for neurological symptoms in patients with carotid artery stenosis. Methods and Results: Asymptomatic (n = 76) and symptomatic (n = 69) patients were evaluated. Serum levels of collagenases (MMP-1, -8), gelatinases (MMP-2, -9), stromelysin (MMP-3), matrilysin (MMP-7), and TIMP-1, -2 were determined by enzyme-linked immunosorbant assay (ELISA). Furthermore, fibrinogen, C-reactive protein (CRP), leukocytes, and further serological parameters were measured. Circulating MMP-7, -8, -9, and TIMP-1 were significantly enhanced in symptomatic individuals with P < .001 for MMP-7 and P < .05 for MMP-8, -9, and TIMP-1. Significant correlations were found between various MMPs with highest correlation coefficient of r = .749 between MMP-8 and -9. In addition, MMP-1, -3, -7, -9 correlated significantly with leukocytes, MMP-1, and TIMP-1 with thrombocytes, MMP-8 with fibrinogen, and MMP-7 with creatinine. Combination of more than one biomarker led to significantly enhanced positive predictive value (PPV) for neurological symptom compared to single MMP (MMP-7 + MMP-9: PPV = 73.1%, MMP-7 + MMP-8 + MMP-9: PPV = 73.8% vs. PPV = 62.5%; P < .001). Conclusions: Thus, using appropriate analytical approaches, we showed for the first time the possibility to use set of relevant biomarkers as predictors of neurological symptoms. Such biomarkers together with current diagnostic techniques may further contribute to recognize vulnerable lesions to define patients at risk.

Photoplethysmography, an Easy and Accurate Method for Measuring Ankle Brachial Pressure Index: Can Photoplethysmography Replace Doppler?

Khandanpour, N., Armon, M., Jennings, B., Clark, A., Meyer, F. — Wed, 29 Jul 2009 02:24:47 PDT

Objective: To assess the accuracy of ankle brachial pressure index (ABPI) assessed by photoplethysmography (PPG) compared with continuous wave Doppler (CW-Doppler). Methods: Ankle brachial pressure index was measured in a standard manner using both PPG and Doppler probes. For PPG-ABPI, a PPG probe was placed on the index finger and great toe, and a microcomputer determined the ABPI. These values were compared with the ABPI measured manually using an 8-MHz Doppler probe. Correlation and agreement between PPG and Doppler ABPI were assessed by Lin’s correlation coefficient and Bland–Altman plots. Results: In all, 133 claudicants were assessed. There was a strong correlation between the 2 ABPI methods (β = .79 and 95% limits of agreement of –0.23 to 0.24). Conclusion: Measuring ABPI automatically using the PPG technique is an effective alternative for Doppler ABPI. PPG-ABPI is completely objective, fast, and accurate.

Is Atherectomy the Best First-Line Therapy for Limb Salvage in Patients With Critical Limb Ischemia?

Wed, 29 Jul 2009 02:24:45 PDT

Objective: To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia. Methods: Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed. Results: A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04). Conclusions: Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.

Great Saphenous Vein Harvesting: A Systematic Review and Meta-Analysis of Open Versus Endoscopic Techniques

Cadwallader, R. A., Walsh, S., Cooper, D., Tang, T., Sadat, U., Boyle, J. — Wed, 29 Jul 2009 02:24:46 PDT

Background: The great saphenous vein is frequently harvested for use as a conduit in lower limb bypass surgery. A number of papers advocate the use of an endoscopic technique rather than a traditional open technique to minimize the associated morbidity. We undertook a systematic review and meta-analysis to compare morbidity associated with these 2 techniques. Method: Medline, PubMed, and secondary referencing identified 16 randomized control trials comparing these 2 methods of harvesting. Primary outcome measures were infection, hematoma, and wound dehiscence and pooled odds ratios (POR) were calculated using a random effects model. Results: Sixteen trials (3689 patients) were identified. Overall complications (POR 7.03), infection (POR 8.08), and wound dehiscence (POR 8.23) were all significantly more common in the open harvesting group compared to the endoscopic group. Conclusion: Endoscopic techniques have a role in vein harvesting but are operator dependent and therefore are only a preferable modality compared to open harvesting methods in experienced hands. More research is required to establish whether long-term patency rates are comparable for the 2 techniques.