Vascular and Endovascular Surgery current issue

Primary Prophylaxis of Venous Thromboembolism in Surgical Patients

Rawat, A., Huynh, T. T., Peden, E. K., Kougias, P., Lin, P. H. — 2008-07-30

Venous thromboembolism is a major risk for surgical patients during the perioperative period. Prevention of perioperative venous thromboembolism remains a critical component of surgical patient care. The risk for venous thromboembolism in surgical patients can be stratified by their risk factors and by the type of operation. Pharmacological prophylaxis for venous thromboembolism includes unfractionated heparin, low—molecular weight heparin, fondaparinux, warfarin, antiplatelet therapy, and direct thrombin inhibitors. Mechanical devices such as graduated compression stockings, intermittent pneumatic compressions, and venous foot pumps are also effective modalities for venous thromboembolism prophylaxis. The optimal preventive measure of venous thromboembolism should be based on the degree of risk for venous thromboembolism with the intensity of prophylaxis while balancing potential treatment benefits and risks in each individual patient. The epidemiology of venous thromboembolism, the methods for achieving venous thromboembolism prophylaxis, and the approach to institute venous thromboembolism prophylaxis in surgical patients undergoing various operative interventions are reviewed in this article.

Prognostic Factors and Treatment Outcome in Mesenteric Vein Thrombosis

2008-07-30

Background Mesenteric vein thrombosis (MVT) can result in intestinal ischemia and is associated with high morbidity and mortality due in part to its frequent delay in diagnosis. The purpose of this study was to evaluate clinical presentation, diagnostic evaluation, and treatment outcome of MVT.

Methods Hospital records and clinical data of all patients treated for MVT were reviewed during a recent 14-year period. Clinical outcome and factors affecting survival were analyzed.

Results A total of 68 patients were included in the study. Abdominal exploration was performed in 23 patients (34%), and second-look operation was necessary in 18 patients (26%). Three patients (4%) underwent unsuccessful operative mesenteric vein thrombectomy, whereas percutaneous transhepatic mesenteric thrombectomy was performed successfully in 3 patients (4%). The 30-day mortality rate was 20%. Forty-six of the 54 survivors were treated with long-term oral anticoagulation therapy. Actuarial survival at 2, 4, 6, and 10 years was 68%, 57%, 43%, and 22%, respectively. Risk factor analysis showed malignancy (P < .002), age >60 years (P < .005), cirrhosis (P < .02), symptom duration (P < .005), and bowel resection (P < .03) were associated with mortality. Logistic regression analysis showed age >60 years (odds ratio [OR], 3.64; P = .03), malignancy (OR, 3.88; P = .02), and prolonged symptom duration (OR, 5.62; P = .01) were independent predictors of mortality.

Conclusions MVT is associated with significant mortality. Prompt diagnostic evaluation with computed tomography may reduce potential treatment delay. Underlying malignancy, advanced age, and prolonged symptom duration are predictive of poor outcome.

Complications Associated With the Arterial Puncture Closure Device--Angio-Seal

2008-07-30

Background Arterial puncture closure devices (APCD) are frequently used after cardiac catheterization. Here, the diagnosis and therapy of femoral artery complications after the use of the Angio-Seal APCD is reported.

Patients and methods The Angio-Seal APCD was deployed in 1600 patients undergoing transfemoral catheterization.

Results In 7 of 1600 cases (0.4%) vascular complications occurred following Angio-Seal deployment. Diagnosis was made by duplex sonography. Intraoperative findings consisted of a complete occlusion with dissection of the femoral artery in all patients. In 6 cases, the femoral bifurcation had to be reconstructed after endarterectomy. Follow-up is complete with a mean of 6 months.

Conclusion The Angio-Seal device should not be used for closure of the superficial femoral artery and in patients with severe arteriosclerosis. The application of arteriography as well as the use of ultrasound-guided puncture is advisable. In all cases, surgical intervention was successful and an adequate therapy for management of complications.

Endovascular Repair of Hemodialysis Graft-Related Pseudoaneurysm: An Alternative Treatment Strategy in Salvaging Failing Dialysis Access

2008-07-30

Introduction Hemodialysis access—related pseudoaneurysm is a known complication in patients requiring hemodialysis via prosthetic arteriovenous grafts (AVGs). The traditional treatment strategy of AVG-related pseudoaneurysms is either AVG ligation or interposition replacement with another prosthetic graft segment or autogenous veins.

Patients and methods From June 2002 to August 2007, 32 self-expanding stent grafts were implanted in 26 patients with AVG pseudoaneurysms. Indications for treatment consisted of large AVG pseudoaneurysm size, localized pain at pseudoaneurysm site, enlarging pseudoaneurysm, and skin site breakdown. AVG pseudoaneurysm exclusion was accomplished with Wallgrafts, Viabahn endoprosthesis, and Fluency endograft. Technical success was achieved in all patients. Nineteen patients experienced a marked decrease in the size of their pseudoaneurysm following endograft exclusion. Successful hemodialysis was resumed through endograft-excluded AVG in all patients within 48 hours.

Conclusions Endoluminal exclusion of AVG pseudoaneurysms using endografts is a safe and effective treatment strategy in patients with hemodialysis-related pseudoaneurysm.

High Ligation of the Saphenofemoral Junction in Endovenous Obliteration of Varicose Veins

Boros, M. J., O'Brien, S. P., McLaren, J. T., Collins, J. T. — 2008-07-30

Background Endovenous radiofrequency (RF) ablation of the greater saphenous vein has become an accepted treatment modality. This study examines if it is necessary to perform high ligation of the saphenous vein to insure success of the procedure.

Study design A retrospective chart analysis was conducted on 219 patients who underwent RF ablation for venous insufficiency. All procedures were performed by 3 board-certified vascular surgeons. One surgeon always ligated the saphenofemoral junction (SFJ), the second never ligated, and the third ligated selectively. Demographic data were collected and analyzed.

Results A total of 77 patients underwent RF ablation with ligation of the SFJ (group I), and 142 patients underwent ablation without ligation (group II). Both groups had similar ablation success rates (P = .0960), 92% (group I) and 84% (group II).

Conclusion Saphenofemoral junction ligation is not indicated on a routine basis to achieve success with endovascular ablation of the greater saphenous vein.

Cryoperforator Surgery: A New Treatment of Incompetent Perforating Veins

Klem, T. M. A. L., Wittens, C. H. A. — 2008-07-30

This study was conducted to determine the feasibility of cryoperforator surgery in the treatment of incompetent perforating veins. Fifteen patients with C2-C4 varicose disease (according to the Clinical-Etiology-Anatomy-Pathophysiology classification) were enrolled in this study. Under local anesthesia, incompetent perforating veins were treated with a duplex-guided cryoprobe. Duplex scans were performed 2 and 4 weeks after treatment. Fifteen patients with 28 incompetent perforating veins were treated with cryoperforator surgery. Distribution of the incompetent perforating veins was as follows: posterior tibial perforator, 12; paratibial perforator, 11; intergemellar perforator, 1; lateral leg perforator, 4 (range = 1-5 incompetent perforating veins per patient). Follow-up showed successful treatment of 12 incompetent perforating veins (43%). This study showed that cryoperforator surgery is feasible for treatment of incompetent perforating veins. Higher success rates could be obtained with our modified diamond-dust coated cryoprobe. Major advantages are the treatment in an outpatient setting and the possibility of treating all incompetent perforating veins, intraluminal or extraluminal.

Efficacy of Closed Suction Drainage in Lower Limb Arterial Surgery: A Meta-Analysis of Published Clinical Trials

2008-07-30

Background Suction drains are widely used in vascular surgery, despite the absence of specific evidence that they confer benefit to patients. There has been no systematic review of the available evidence, though drainage has been shown to confer no benefit, or indeed harm, across a variety of surgical disciplines. Accordingly, a systematic review and meta-analysis of the current evidence base for closed suction drainage following surgical lower limb revascularization was undertaken.

Methods Medline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized controlled trials of the use of surgical drains. The primary outcomes were wound infection, seroma/lymphocele formation, and hematoma formation. Pooled odds ratios were calculated for categorical outcomes.

Results Four trials containing 429 groin wounds were eligible for inclusion. There was no significant effect on wound infection, seroma/lymphocele formation, or hematoma formation.

Conclusion Our meta-analysis suggests that no benefit is conferred by wound drainage following lower limb revascularization. The practice incurs avoidable expense and should not be routinely used.

High-Sensitivity CRP Is Correlated With Neurologic Symptoms and Plaque Instability in Patients With Severe Stenosis of the Carotid Bifurcation

2008-07-30

The aim of this study is to investigate the correlation of high-sensitivity C-reactive protein and E-selectin with clinical manifestations and plaque characteristics in 88 patients (69 with and 19 without neurological symptoms) with high-grade stenosis of the carotid bifurcation who underwent endarterectomy. The grade of stenosis was quantified by duplex ultrasonography and digital subtraction angiography. Preoperatively, serum high-sensitivity C-reactive protein and E-selectin were measured. Postoperatively, carotid plaque morphology was established according to the American Heart Association classification. High-sensitivity C-reactive protein levels were significantly (P < .001) higher in symptomatic than in asymptomatic patients, as well as in patients with unstable compared with those with stable plaques (P < .001). Serum high-sensitivity C-reactive protein levels correlated significantly ( P < .05) with macrophage count on the plaque. In conclusion, serum high-sensitivity C-reactive protein levels are associated with presence of neurological symptoms and plaque instability in patients with high-grade stenosis of the carotid bifurcation.

Thrombospondin-1-Induced Migration Is Functionally Dependent Upon Focal Adhesion Kinase

2008-07-30

Vascular smooth muscle cell migration is important in vascular disease. Previously, we showed thrombospondin-1 activates focal adhesion kinase in these cells. We hypothesized that focal adhesion kinase is important for thrombspondin-1-induced vascular smooth muscle cell migration. Bovine aortic smooth muscle cells were transfected with FAK397, FAK-wild type, pcDNA, or β-Gal plasmids. Migration was assessed with thrombospondin-1 or serum-free medium in quiescent transfected cells or quiescent cells pretreated with the focal adhesion kinase inhibitor, geldanamycin. Number of cells migrated per 5 fields (x400) were recorded. Antihemagglutinin immunoprecipitation and Western blot were used to examine thrombospondin-1-induced focal adhesion kinase phosphorylation in transfected cells. FAK397 transfection inhibited thrombospondin-1-induced focal adhesion kinase phosphorylation and migration (P < .05). Geldanamycin inhibited thrombospondin-1-induced smooth muscle cell migration (P < .05). In conclusion, vascular smooth muscle cells transfected with FAK397 inhibited thrombosponin-1-induced migration and tyrosine phosphorylation. Further, geldanamycin also inhibited migration. These results suggest focal adhesion kinase is involved in thrombospondin-1-induced vascular smooth muscle cell migration.

Atrial Natriuretic Peptide Protects Against Ischemia-Reperfusion Injury in Rabbit Hearts In Vivo

Zhang, W. W., Hasaniya, N. W., Premaratne, S., McNamara, J. J. — 2008-07-30

The aim of this study is to investigate whether atrial natriuretic peptide can mimic preconditioning to protect ischemia or reperfusion injury in rabbit hearts. New Zealand white rabbits were randomized into 3 groups: (1) Controls. Hearts received a 60 minute-occlusion of the left anterior descending artery, followed by a 180 minute-reperfusion. (2) Preconditioning. Two 5-minute periods of ischemia separated by a 10-minute reperfusion, followed by a 60-minute ischemia and a 180-minute reperfusion. (3) Atrial natriuretic peptide treatment. Bolus injection of exogenous atrial natriuretic peptide (2.5 µg/kg) given intravenously at 15 minutes prior to 60 minute-ischemia followed by a 180-minute reperfusion. Myocardial necrotic area and area at risk of necrosis were determined by triphenyltetrazolium chloride staining. Ratio of necrotic area to area at risk was 49.95% ± 1.15%, 7.95% ± 0.33%, and 8.36% ± 0.61% in the controls, preconditioning group, and atrial natriuretic peptide group, respectively. Both preconditioning and atrial natriuretic peptide significantly reduced the size of infarct caused by ischemia (preconditioning vs controls, P < .05; atrial natriuretic peptide vs controls, P < .05). Atrial natriuretic peptide can mimic ischemic preconditioning to protect rabbit hearts from prolonged ischemia and reperfusion injury. It may be involved in the cardioprotective mechanisms of preconditioning.

Aortoduodenal Fistula and Streptococcal Myonecrosis

Abdelrazeq, A. S., Owais, A. E., Mukdad, F., Aldoori, M. I. — 2008-07-30

Pyomyositis is a rare primary bacterial infection of the skeletal muscles. Pyomyonecrosis is the most severe manifestation of this disease and is associated with a potentially devastating outcome. Patients with peripheral vascular disease presenting with pyomyositis may be difficult to distinguish from those with critical ischemia or synthetic graft sepsis. This article reports on a patient with aortobifemoral bypass graft and severe vitamin B₁₂ deficiency who developed pyomyonecrosis and aortoduodenal fistula. This article highlights the etiologic dilemma, diagnostic difficulties, and management challenges inherent in such cases. Pitfalls in our management of this patient are discussed.

Repair of the Inferior Vena Cava With Autogenous Peritoneo-Fascial Patch Graft Following Abdominal Trauma: A Case Report

Emmiler, M., Kocogullari, C. U., Yilmaz, S., Cekirdekci, A. — 2008-07-30

Abdominal vascular injuries are among the most challenging and lethal injuries in traumatized patients. Inferior vena cava is the most frequently injured vein during the blunt or penetrating trauma. The primary repair, end to end anastomosis, endovascular stenting, or graft interposition with autogenous or synthetic materials should be considered in selected cases. However, in cases the synthetic graft was preferred, intestinal contaminations due to small or large bowel perforation accompanying the trauma have been cited as a limiting factor for the use of such grafts as in the current case. However, a previous history of lower leg variceal surgery prevents the use of great saphenous vein as a graft. So in the present case, the authors report a patient with inferior vena cava injury repaired with autogenous peritoneo-fascial graft. The authors have used APF graft in traumatic inferior vena cava injury for the first time.

Endovascular Treatment of a Symptomatic Carotid Artery Aneurysm With a Stent Graft

Bellosta, R., Sesana, M., Baglini, R., Luzzani, L., Talarico, M., Sarcina, A. — 2008-07-30

Endovascular methods have become more widespread and offer an alternative to surgery, which is often difficult in case of a hostile neck resulting from radiotherapy. Carotid pseudoaneurysm after laryngectomy is a very uncommon complication. We report a case of symptomatic carotid artery pseudoaneurysm treated using a stent graft.

Endovascular Repair of a Spontaneous Right Common Iliac Artery--Inferior Vena Cava Fistula Due to Infrarenal Aortoiliac Aneurysm

Se Hwan Kwon, , Joo Hyeong Oh, , Sun Jin Park, , Ho Chul Park, — 2008-07-30

Most abdominal aortic aneurysms are asymptomatic, but 1% to 4% of cases present with a life-threatening complication. A spontaneous right common iliac artery—inferior vena cava fistula, a rare condition caused by infrarenal aortoiliac aneurysm, is reported. In this case, the condition was successfully managed with primary endovascular stent-graft treatment.

Treatment of Spontaneous Lumbar Artery Pseudoaneurysm by Computed Tomography--Guided Thrombin Injection

Sharma, D., Elmore, J. R., Nadal, L. L., Sheldon, D. G., Franklin, D. P. — 2008-07-30

A case of spontaneous pseudoaneurysm of a lumbar artery that was treated with computed tomography— guided thrombin injection is reported in this study. To the authors' knowledge, pseudoaneurysm of lumbar artery without any predisposing factors has been reported only twice in the literature previously. The aims of this case report are to discuss the differential diagnosis and management of this difficult problem.

Endovascular Treatment of a "Fishy" Ulcer Caused by a Traumatic Arteriovenous Fistula

Tiwari, A., Harrington, T., Vicaretti, M. — 2008-07-30

Arteriovenous fistula secondary to trauma is an uncommon cause of leg ulcers. In this article, an unusual case of a nonhealing leg ulcer caused by a stingray is described. This case highlights the difficulty in diagnosing and treating nonhealing ulcers secondary to arteriovenous fistula.

Endovascular Management of an Arteriovenous Fistula and Concomitant Pseudoaneurysm in an Intravenous Drug Abuser

Sadat, U., Noor, N., See, T. C., Hayes, P. D. — 2008-07-30

An interesting case of an intravenous drug abuser who had endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm, resulting from recurrent puncture of the femoral artery is reported in this study.

Statin Therapy Enhance Benefit of Exercise Training in Patients With Claudication Intermittens

Carlon, R., Zanchetta, M. — 2008-07-30