Vascular and Endovascular Surgery current issue

The GALA Trial: Will It Influence Clinical Practice?

Paraskevas, K. I., Mikhailidis, D. P., Bell, P. R.F. — Thu, 22 Oct 2009 02:33:26 PDT

The General Anesthesia vs. Local Anesthesia for Carotid Surgery (GALA) trial did not show a difference in 30-day postoperative stroke, myocardial infarction and death rates between patients undergoing carotid endarterectomy (CEA) under local vs. general anesthesia. The present article discusses some limitations of the GALA trial. Firstly, the expected stroke and death rates following CEA is so low, that it was unlikely that the GALA trial would show any significant difference between local and general anesthesia. Secondly, preoperative statin use was not recorded. Thirdly, intraoperative shunt usa ge rates (a possible parameter for the development of stroke) varied considerably between the 2 groups (43% vs. 14%, for general vs. local anesthesia, respectively; P < .0001), as well as between UK and non-UK surgeons who always (73.6% vs. 20.8%, respectively; P < .0001), never (4.2% vs. 26%, respectively; P < .0002), or selectively (22.2% vs. 53.2%, respectively; P < .0001) used a shunt. Furthermore, no information was provided regarding the type of shunts used; for example, atraumatic shunts may be associated with lower perioperative stroke rates. These limitations could influence the interpretation of the results of the GALA trial. Due to lack of differences between the 2 groups and the presence of the above limitations, it seems likely that this trial will have little effect on clinical practice.

Intra-Arterial Transplantation of Adult Bone Marrow Cells Restores Blood Flow and Regenerates Skeletal Muscle in Ischemic Limbs

Liu, Q., Chen, Z., Terry, T., McNatt, J. M., Willerson, J. T., Zoldhelyi, P. — Thu, 22 Oct 2009 02:33:26 PDT

Objective: Bone marrow cell therapy promotes angiogenesis, but the cellular fate of bone marrow cells (BMCs) in the absence of immunosuppressant interventions is unclear. We created a model of severe hind limb ischemia to address whether BMCs form new blood vessels or differentiate into other tissues. Methods and Results: After ligating the common femoral artery in ApoE knockout mice, we injected either phosphate buffered saline (PBS) or 5 x 10⁷ adult unfractionated BMCs obtained from green fluorescent protein-positive mice. Laser Doppler imaging of the ischemic limbs revealed that intra-arterial BMCs significantly increased blood flow recovery in ischemic limbs beginning 21 days after surgery and peaking at 27 days (61.8% ± 15% vs. 41.9% ± 13.9%, respectively, for BMCs and PBS, P < .05). The BMCs differentiated into small blood vessels, skeletal myofibers, and supporting membranes, and these changes were associated with increased serum levels of vascular endothelial growth factor (VEGF), fibroblast growth factor 2 (FGF-2), transforming growth factor β (TGFβ), interleukin 4 (IL-4), and tumor necrosis factor (TNF-). Conclusions: Adult BMCs injected into ischemic limbs without immunosuppressant therapy differentiated into blood vessels and skeletal myofibers, and this was associated with accelerated blood flow restoration and increased serum levels of VEGF, FGF-2, TGF-β, IL-4, and TNF-. Skeletal muscle formation may provide benefits beyond angiogenesis to patients with chronic peripheral arterial disease or to patients with low cardiac output states who also suffer from skeletal muscle atrophy.

Effect of PJ34 on Spinal Cord Tissue Viability and Gene Expression in a Murine Model of Thoracic Aortic Reperfusion Injury

Thu, 22 Oct 2009 02:33:26 PDT

Introduction: These studies were designed to determine whether PJ34, a novel Poly-ADP Ribose Polymerase Inhibitor, modulates expression of markers of stress and inflammation in the spinal cord following ischemia/ reperfusion(TAR). Methods: 129S1/SvImj mice were subjected to thoracic aortic occlusion and 48 hours of reperfusion (n = 38). Experimental Groups included: Untreated Control (UC, n = 21); PJ34 (PJ34, n = 11) and sham (S, n = 6). At 48 hours, mice were euthanized for mRNA analysis and assessment of spinal cord viability. Results: PJ34 improved spinal cord tissue viability following TAR (UC:53.1 ± 6.3, PJ34:73.5 ± 4.1% sham, p < 0.01). mRNA analysis revealed significant expression of stress response genes in UC and PJ34 treated mice. Conclusions: PJ34 enhanced mitochondrial activity and preserved neurologic function following TAR despite the expression of stress and pro-inflammatory markers within the spinal cord. The ongoing cord stress response in neurologically intact PJ34 treated mice may indicate the potential to develop delayed neurologic dysfunction.

Intermittent Roxithromycin for Preventing Progression of Small Abdominal Aortic Aneurysms: Long-Term Results of a Small Clinical Trial

Thu, 22 Oct 2009 02:33:26 PDT

Background: Antibodies against Chlamydia pneumoniae are associated with an increased rate of expansion of small abdominal aortic aneurysms (AAAs). Short-term follow-up trials have shown a transient reduction AAA growth rate, in macrolide treated compared with placebo. Therefore we analysed the influence of intermittent, long-term roxithromycin treatment on AAA expansion and referral for surgery. Methods: Eighty-four patients with small AAAs were randomized to either an annual 4 weeks’ treatment with roxithromycin or placebo, and followed prospectively. Results: Intermittent, long-term Roxithromycin-treatment reduced mean annual growth rate by 36% compared with placebo after adjustment for potential confounders. Long-term roxithromycin-treated patients had a 29% lower risk of being referred for surgical evaluation, increasing to 57% after adjusting for potential confounders. Conclusion: Annual 4 week treatment with 300 mg roxithromycin daily may reduce the progression of small AAAs, and later need for surgical repair. However, more robust studies are needed for confirmation.

Carotid Body Tumor Surgery: Management and Outcomes in the Nation

Vogel, T. R., Mousa, A. Y., Dombrovskiy, V. Y., Haser, P. B., Graham, A. M. — Thu, 22 Oct 2009 02:33:26 PDT

Objective: To evaluate the impact of carotid reconstruction (REC) and pre-operative embolization (EMB) for Carotid Body Tumor (CBT) surgery. Methods: Retrospective study utilizing the Nationwide Inpatient Sample (2002-2006). Results: 2117 patients (mean age 56.5 ± 17.2 years) underwent CBT surgery: 1686 excision alone (EX); 129 excision with embolization (EX+EMB); and 302 excision with carotid artery reconstruction (EX+REC). EX+REC compared to EX had greater rates of mortality (1.61%vs.0.59%; P =.0495), stroke (17.7% vs. 3.5%; P < .0002), and postoperative hemorrhage (43.1% vs. 2.4%; P < 0.002). EX+EMB did not demonstrate increased mortality or stroke compared to EX and the rate of postoperative hematoma was similar between groups (P = .3144). Conclusions: CBT resection is a relatively rare procedure and when combined with EMB was more expensive, but was associated with significantly fewer complications and decreased blood product utilization. These data suggest that CBT surgery requiring carotid reconstruction carries significant morbidity and that EMB as an adjunctive tool was beneficial for CBT surgery outcomes.

Is Infrainguinal Percutaneous Atherectomy Better Suited for Certain Arteries Than Others?

Kolakowski, S., Calligaro, K. D., Dougherty, M. J. — Thu, 22 Oct 2009 02:33:26 PDT

Objective: We analyzed our results with percutaneous rotational atherectomy catheters and specifically examined whether they were more likely to be associated with a successful outcome when used to treat smaller diameter vessels such as infrapopliteal (IP) arteries compared to larger diameter femoropopliteal (FP) arteries and infrainguinal arterial autogenous vein grafts (GRAFTS). Material and Methods: Between January 1, 2005, and December 31, 2006, athrectomies were performed on 32 patients for claudication (14), gangrene (9), rest pain (4), and failing GRAFTS (5). Treated vessels included 14 superficial femoral, 1 popliteal, 5 anterior tibial, 4 posterior tibial, and 3 peroneal arteries along with 5 failing GRAFTS. All procedures were performed by vascular surgeons in an endovascular operating suite using a mobile C-arm. Results for larger diameter vessels including FP arteries and GRAFTS were combined (FP + BYPASSES) and compared to results of IP artery lesions. Follow-up averaged 10 weeks (range, 0.5-34 weeks). Results: Length of treated lesions averaged 4.2 cm (range, 1—15 cm) for FP + GRAFT lesions (9 occlusions, 11 stenoses) versus 1.8 cm (1-4 cm) for IP lesions (6 occlusions, 6 stenoses; P = ns). Procedural success rate based on postoperative segmental pressures, pulse volume recordings, and duplex ultrasound was 70% (14/20) for FP + GRAFTS versus 83% (10/12) for IP lesions (P = .03). Need for concomitant adjunctive balloon angioplasty to treat residual stenosis tended to be higher for FP + GRAFT lesions (40% [8/20]) compared to IP lesions (25% [3/12]; P = ns). During follow-up, 25% (5/20) of FP + GRAFTS lesions required reintervention (3 balloon angioplasties, 1 thrombectomy, 1 GRAFT pseudoaneurysm) versus none for the IP lesions (P = .03). Limb salvage rates were 90% (18/20) for FP + GRAFT lesions versus 100% (12/12) for IP lesions during this short follow-up. Conclusions: These preliminary results suggest that short segment IP arterial stenoses and occlusions can be successfully treated with atherectomy catheters with a lower rate of reintervention during short-term follow-up, less need for concomitant adjunctive balloon angioplasty and a lower complication rate compared to FP + graft lesions.

Saphenous Laser Ablation at 1470 nm Targets the Vein Wall, Not Blood

Almeida, J., Mackay, E., Javier, J., Mauriello, J., Raines, J. — Thu, 22 Oct 2009 02:33:26 PDT

The 2 primary objectives of this study were to investigate whether the 1470-nm wavelength can close a saphenous vein painlessly and determine safety, efficacy, and side effects of the 1470-nm laser. In all, 26 limbs were treated in the Dominican Republic, with a radially-emitting fiber at low energy ranging from 20 J/cm to 30 J/cm. Perivenous anesthesia was used selectively. Then 41 veins were treated with the 1470-nm laser at 30 J/cm at 5 watts, using standard perivenous tumescent anesthesia in Miami and compared to a historical control (980 nm, 80 J/cm, and 12 watts). We demonstrated that the 1470-nm wavelength endovenous laser system could not close saphenous veins without use of anesthesia. Closure with a dramatic reduction in energy when compared to a 980-nm wavelength control demonstrated a marked reduction in postoperative pain and ecchymosis; this implies that vein-wall perforations are minimized with this system.

The Influence of Total Plasma Homocysteine and Traditional Atherosclerotic Risk Factors on Degree of Abdominal Aortic Aneurysm Tissue Inflammation

Thu, 22 Oct 2009 02:33:26 PDT

Objective: Modulating effects of genetic and environmental risk factors on severity of human abdominal aortic aneurysm (AAA) tissue inflammation remain unclear. We investigated the influence of total plasma homocysteine (tHcy) and traditional atherosclerotic risk factors (ARF) on degree of AAA tissue inflammation. Methods: Aneurysm specimens were obtained from 89 male patients aged 52 to 83 years, underwent asymptomatic not ruptured AAA (mean diameter 5.5 cm) open repair and graded for degree of histologic inflammation. Multivariate analysis was used to determine the association of tHcy and ARF, with degree of inflammation. Results: Current cigarette smoking, odds ratio (OR) 4.4, 95% confidence interval 1.3 to 15.2, P = .01 and no other ARF, neither tHcy levels OR 0.9 (0.9-1.02), P = .2 were associated with high-grade tissue inflammation. Conclusion: These results provide evidence against a major effect of tHcy levels on AAA tissue inflammation, while current cigarette smoking is a significant modulating factor.

Prospective Comparison of the Pneumatic Cuff and Manual Compression Methods in Diagnosing Lower Extremity Venous Reflux

Kakkos, S. K., Lin, J. C., Sparks, J., Telly, M., McPharlin, M., Reddy, D. J. — Thu, 22 Oct 2009 02:33:26 PDT

Aim: To compare pneumatic cuff with manual compression in diagnosing reflux in patients with chronic venous insufficiency (CVI).

Patients and Methods: Eighteen patients (Clinical Etiologic Anatomic Pathophysiologic [CEAP 2-5], median Venous Clinical Severity Score [VCSS 6.5]) were studied. The VenaPulse device (ACI Medical, San Marcos, California) was used for cuff inflation. The hemodynamic performance of the 2 methods was tested in the first 9 patients, while their diagnostic value was tested in the last 9 patients.

Results: Both methods induced equal compression with median peak velocity of the antegrade flow (PVA) being 86 cm/s (P = .65). Coefficient of variation (CV) for PVA in the superficial veins was significantly higher with the manual method (16.8%) compared to the VenaPulse method (9.5%, P <.001), while sensitivity and specificity were 85% and 100%, and 78% ( .68, P <.001) and 100%, respectively.

Conclusions: Pneumatic cuff and manual compression were shown to be equally effective in diagnosing venous reflux. Cost-effectiveness and ease-of-use studies comparing these methods are justified.

Diagnostic Strategies for the Persistent Sciatic Artery

Abularrage, C. J., Crawford, R. S., Patel, V. I., Conrad, M. F. — Thu, 22 Oct 2009 02:33:26 PDT

Persistent sciatic artery (PSA) is a rare congenital vascular anomaly that leads to aneurysmal degeneration and atherosclerotic changes. A careful understanding of the embryology is mandatory as variations in vascular development determine the optimal treatment. We present a case of an 85-year-old female who was incidentally found to have a PSA aneurysm, and review the literature.

Control of Inferior Vena Cava Injury Using Percutaneous Balloon Catheter Occlusion

Bui, T. D., Mills, J. L. — Thu, 22 Oct 2009 02:33:26 PDT

Traumatic inferior vena cava (IVC) injuries are highly lethal and require prompt surgical intervention. Traditional methods of vascular control include manual compression, gentle clamping or balloon occlusion catheters. These open methods require direct dissection into the hematoma for visualization, which can lead to massive hemorrhage. We present a case of percutaneously delivered balloon catheter occlusion for vascular control prior to repair of an infrarenal IVC injury as a potential alternative. This approach achieves complete occlusion of the injury site and allow easier repair of the IVC, thereby reducing operative time and blood loss.

A Combined Endovascular and Open ''Reverse Hybrid'' Technique for Repair of Complex Juxtarenal Inflammatory Aortic Aneurysms

Rigberg, D., Jimenez, J. C., Lawrence, P., Gelabert, H. — Thu, 22 Oct 2009 02:33:26 PDT

Inflammatory abdominal aortic aneurysms (IAAA) can present significant challenges to surgeons, especially in the juxtarenal location where they may not be amenable to endovascular repair. The dense, inflammatory component of these lesions can encase adjacent structures including the duodenum, ureters, and inferior vena cava putting them at risk for injury during open exposure. We report a novel ‘‘reverse hybrid’’ technique using a combined endovascular and open approach for repair of large, juxtarenal IAAA’s.

Intravascular Ultrasound--Guided Inferior Vena Cava Filter Placement in the Military Multitrauma Patients: A Single-Center Experience

Thu, 22 Oct 2009 02:33:26 PDT

Background: High velocity fragments have resulted in a multitude of complex injuries in the military patients, placing them at increased risk of venous thromboembolism. Methods: A retrospective analysis was performed of all the intravascular ultrasound (IVUS)-guided bedside inferior vena cava (IVC) filters placed between August 2003 and October 2007. Results: Fourteen patients had bedside IVUS-guided retrievable filter placement. Thirteen males and one female and the mean (+SD) injury severity scores (ISS) was 37.2 (+9.9). The most common causes of injury were explosive devices (57%), gunshot wounds (28%), rocket-propelled grenades (7%), and motor vehicle crashes (7%). Indications for filter insertion were deep venous thrombosis in 36% of patients and pulmonary embolus in 28%. Thirty five percent had filters inserted prophylactically. Conclusions: Military trauma population ISS is considerably higher than what is reported in the civilian population. The bedside IVUS-guided IVC filter insertion is particularly useful in this population.

Delayed Superficial Femoral Artery Stent Erosion and Pseudoaneurysm Following Endovascular Therapy for Occlusive Disease

Leon, L. R., Goshima, K. R. — Thu, 22 Oct 2009 02:33:26 PDT

A 78 year-old male with multiple serious medical comorbidities was diagnosed with a pseudoaneurysm of the proximal superficial femoral artery. He had undergone successful superficial femoral artery (SFA) stenting for limb salvage four months previously and a Duplex ultrasound had confirmed adequacy of the endovascular procedure two months after its execution. This was successfully treated with placement of a covered-stent at the proximal SFA and a balloon-expandable stent at the origin of the deep femoral artery. Unfortunately the patient expired six weeks after the last endovascular intervention, likely due to procedural-unrelated causes. We postulate delayed stent erosion of a proximal atherosclerotic SFA, causing the pseudoaneurysm. This is the first report of such a case in the literature.

Hypothenar Hammer Syndrome in a Computer Programmer: CTA Diagnosis and Surgical and Endovascular Treatment

Thu, 22 Oct 2009 02:33:26 PDT

Finger ischemia due to embolic occlusion of digital arteries resulting from trauma to the palmar ulnar artery has been termed hypothenar hammer syndrome (HHS). In HHS, arterial thrombosis and/or aneurysm formation with embolization to the digital arteries causes symptoms of ischemia. We describe a patient in whom the initial diagnosis was made on multidetector computed tomographic angiography (CTA), as well as his endovascular and surgical management.

Stent-Graft Placement for Management of Iatrogenic Hepatic Artery Branch Pseudoaneurysm After Liver Transplantation

Ginat, D. T., Saad, W. E. A., Waldman, D. L., Davies, M. G. — Thu, 22 Oct 2009 02:33:26 PDT

Pseudoaneurysm of the hepatic arteries is uncommon following liver transplantation and is usually iatrogenic. We describe a case of balloon angioplasty of a left hepatic artery stenosis complicated by an iatrogenic pseudoaneurysm. Resolution of the stenosis and the pseudoaneurysm was achieved through a combination of a bare stent and a balloon-expandable covered stent. The completion angiogram demonstrated excellent appearance of the patent hepatic arteries with exclusion of the pseudoaneurysm. No surgery was required. The graft and the patient did well for the following 6 months. Doppler ultrasound examination at 2 and 6 months postintervention revealed patent hepatic arteries and no evidence of the pseudoaneurysm.

Endovascular Therapy for Symptomatic Mobile Thrombus of Infrarenal Abdominal Aorta

Luckeroth, P., Steppacher, R., Rohrer, M. J., Eslami, M. H. — Thu, 22 Oct 2009 02:33:27 PDT

Mobile thrombus is a rare cause of distal arterial embolization. We report 2 cases of mobile thrombus of the abdominal aorta leading to distal embolization. Both patients were successfully treated with endovascular exclusion of the thrombus and distal embolectomy. Endovascular exclusion of a mobile thrombus of the abdominal aorta is a significantly less invasive alternative to open abdominal aorta thrombectomy.