Vascular and Endovascular Surgery recent issues

Nicotinamide Adenine Dinucleotide Phosphate Oxidase and Diabetes: Vascular Implications

Maier, K. G. — 2008-08-26

Vascular disease associated with diabetes mellitus is a major cause of morbidity and mortality and is increasing in the United States. It is now recognized that oxidative stress plays a substantial role in the underlying vascular pathology of several diseases, including hypertension and diabetes. In diabetes, there is an increase in the steady state levels of reactive oxygen species. One of the primary generators of reactive oxygen species is nicotinamide adenine dinucleotide phosphate oxidase. Studies have indicated that inhibition of this system is associated with vascular benefits in diabetes. Therefore, there may be a role for therapies directed at nicotinamide adenine dinucleotide phosphate oxidase in this disease. This review will examine the structure, activation, potential role in vascular disease, and benefits of inhibition of nicotinamide adenine dinucleotide phosphate oxidase.

Local Versus Systemic Mechanisms Underlying Supervised Exercise Training for Intermittent Claudication

Stewart, A. HR., Smith, F. CT., Baird, R. N., Lamont, P. M. — 2008-08-26

The mechanisms by which exercise training improves intermittent claudication remain unclear. In this article, the effects of local and systemic physiological factors on improved exercise tolerance after a supervised exercise program in claudicants are investigated. A total of 60 patients were randomized to 3 months of supervised exercise followed by 3 months of unsupervised exercise, or to exercise advice alone (control). Supervised exercise increased both pain-free and maximal walking distances. Heart rate during submaximal exercise and resting mean arterial pressure were lower after supervised exercise at 6 months. Serum lactate at maximum claudication increased significantly after 3 months in the supervised exercise group but this change had resolved by 6 months. Symptomatic improvement was accompanied by modest reductions in mean arterial pressure and submaximal heart rate on exercise. Increased serum lactate at maximum claudication subsequently declined despite continued improvement in walking distance, suggesting local adaptations to improve efficiency of muscle oxygen delivery and/or utilization.

No Gender Influences on Clinical Outcomes or Durability of Repair Following Carotid Angioplasty With Stenting and Carotid Endarterectomy

Park, B., Aiello, F., Dahn, M. S., Menzoian, J. O., Mavanur, A. — 2008-08-26

Introduction To determine if gender influences clinical outcomes and durability of repair after carotid angioplasty with stenting (CAS) or carotid endartercetomy (CEA), an analysis of patient records was performed.

Methods This study included 89 CAS patients (47 men and 42 women) and 93 CEA patients (53 men and 40 women). Patients underwent duplex scans 6, 12, 24 months postprocedure. The outcomes of periprocedural mortality, major adverse events, strokes, and myocardial infarctions were assessed. Incidence of critical restenosis and recurrence of symptoms was also assessed.

Results No significant differences were noted between men and women who had undergone either CAS or CEA (P > .05) for clinical outcomes and durability of repair. No differences for periprocedural mortality, major adverse events, critical restenosis, recurrent neurologic symptoms, and adverse event free survival were found.

Conclusions These results do not indicate substantial gender influences on clinical outcomes or durability of repair following CAS and CEA.

Low-Dose Aspirin May Prevent Growth and Later Surgical Repair of Medium-Sized Abdominal Aortic Aneurysms

2008-08-26

Experimental data suggest that aspirin-induced platelet inhibition may retard growth of abdominal aortic aneurysms. In this article, whether low-dose aspirin use is associated with reduced aneurysm progression and subsequent need for surgery is examined. In this observational cohort study within a screening trial, 148 patients with small aneurysms (maximum diameter 30-48 mm) annually are followed. Patients were referred for surgery when the aneurysmal diameter exceeded 50 mm. Median follow-up time was 6.6 years. Among patients whose abdominal aortic aneurysms were initially 40 to 49 mm in size, the abdominal aortic aneurysm expansion rate for low-dose aspirin users compared with nonusers was 2.92 mm/y versus 5.18 mm/y (difference 2.27 mm/y, 95% CI, 0.42-4.11). No difference in expansion rates and risk ratios for operative repair was found for patients with abdominal aortic aneurysms <40 mm. For medium-sized abdominal aortic aneurysms, low-dose aspirin may prevent abdominal aortic aneurysm growth and need for subsequent repair, but residual confounding cannot be excluded.

Single-Center Experience of Caval Thrombectomy in Patients With Renal Cell Carcinoma With Tumor Thrombus Extension Into the Inferior Vena Cava

2008-08-26

The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1—54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.

C-Reactive Protein Predicts Future Arterial and Cardiovascular Events in Patients With Symptomatic Peripheral Arterial Disease

Hogh, A. L., Joensen, J., Lindholt, J. S., Jacobsen, M. R., Ostergaard, L. — 2008-08-26

High-sensitivity C-reactive protein is associated with increased risk of cardiovascular events. Consequently, the predictive value of this protein in patients with symptomatic peripheral arterial disease was examined. In all, 452 patients with symptomatic peripheral arterial disease had high-sensitivity C-reactive protein measured at baseline (mean follow-up = 2.1 ± 1.4 years). Events were defined as primary (death, amputation, or peripheral revascularization) or secondary (lower limb thrombosis, myocardial infarction, or stroke).The level of high-sensitivity C-reactive protein was significantly higher among those dying (P = .04), those who needed amputation (P = .01), and those developing an overall secondary endpoint (P = .02). By receiver-operating characteristic curve analysis, the optimal cutoff point was constantly approximately 10 to 20 mg/L with a sensitivity and specificity of 56% to 63% and 54% to 56%, respectively. Baseline levels of high-sensitivity C-reactive protein are associated with future arterial events in symptomatic peripheral arterial disease patients but cannot stand alone as a predictive tool.

Natural History of the Great Saphenous Vein Stump Following Endovenous Laser Therapy

Pleister, I., Evans, J., Vaccaro, P. S., Satiani, B. — 2008-08-26

Background: Little is known about the ideal residual length of the great saphenous vein (GSV) stump and its potential role in complications such as acute deep venous thrombosis (DVT) and recanalization. This study was designed to learn about the natural history of the residual GSV stump length following endovenous laser treatment. Methods: Prospective data were collected from 50 limbs of 50 patients over an 11-month period. Clinical assessment and duplex ultrasound were performed preoperatively, at 24 hours and at 3 months after the procedure. Results: The residual GSV stump decreased in length from a mean of 15 mm at 24 hours to 13 mm at 3 months after the procedure. None of the patients developed acute DVT or proximal recanalization when the laser tip was positioned 28 mm distal to the saphenofemoral junction. Conclusion: Endovenous laser therapy of the GSV for symptomatic reflux is safe and effective. The residual GSV stump decreased in length over a 3-month period.

The Role of Statin Drugs in the Management of the Peripheral Vascular Patient

Samson, R. H. — 2008-08-26

The impact of statin therapy on established vascular conditions and recurrent disease is most relevant for long-term care. Patients receiving statin therapy have been shown to experience less recurrent stenosis following carotid endarterectomy and stent angioplasty, reduced cardiac events following cardiac and noncardiac vascular surgery, and reduction in aneurysm development. In patients with peripheral arterial disease, claudication distance is increased, as well as patency rates following infrainguinal arterial bypass grafting. Of note, statins drugs may also prove beneficial in the prevention of certain cancers, Alzheimer's disease, and osteoporosis (all diseases frequently seen concurrently in the patient with peripheral arterial disease). As such, it is becoming all the more necessary that vascular surgeons remain informed about clinical research initiatives related to statin use and lipid management in general. The following is a review of lipid metabolism as it applies to statins as well as a review of the beneficial effects of statins.

Mitogen-Activated Protein Kinase p38 Pathway in Venous Ulcer Fibroblasts

Raffetto, J. D., Gram, C. H., Overman, K. C., Menzoian, J. O. — 2008-08-26

Objective: Venous ulcer fibroblasts (w-fb) have attenuated growth compared to normal fibroblasts (n-fb). The MAPKp38 pathway mediates stress-responses in various diseases. We hypothesize that p38 pathway is altered in w-fb. Methods: W-fb were isolated from venous ulcers and n-fb from the ipsilateral thigh. Fibroblasts were analyzed for phosphorylated p38 using immunoblot. The relation between p38 and w-fb proliferation was assessed with SB203580 (p38 inhibitor). Fibroblasts were treated with bFGF, TNF-a, and IL-1 and p38 expression analyzed. Results: Phosphorylated p38 expression was increased in w-fb (AU%=233.5±59.7, P=0.039) compared to n-fb (AU%=99.9±14.6). W-fb treated with SB203580 demonstrated increased growth compared to untreated w-fb. W-fb treated with bFGF demonstrated decreased p38. TNF- and IL-1β significantly increase p38 expression. Conclusions: MAPK p38 is up-regulated in w-fb. Regulation of w-fb proliferation is influenced by p38. Altering the p38 pathway in vivo with growth factors or cytokine inhibition may improve fibroblast proliferation and venous ulcer healing.

Catheter-Directed Thrombolysis for Acute Renal Artery Thrombosis: Report of 4 Cases

2008-08-26

Acute renal artery occlusion is a rare but threatening problem; optimal therapeutic treatment remains a challenge, and ultimate outcomes are still to be defined. In the last decades, several reports or short-case experiences have been reported describing the use of selective infusion of lytic agents into renal artery to treat acute occlusion. We report 4 cases of acute renal artery occlusion treated by catheter-directed intraarterial thrombolysis.

Bilateral Popliteal Artery Occlusion in a Competitive Bike Rider: Case Report and Clinical Review

McAree, B. J., O'Donnell, M. E., Davison, G. W., Boyd, C., Lee, B., Soong, C. V. — 2008-08-26

Since its first description in 1879, popliteal artery entrapment syndrome remains a debilitating condition, which frequently affects young active people. Increased awareness of popliteal artery entrapment syndrome combined with improvements in investigative modalities has resulted in a more frequent diagnosis of this eminently treatable condition. In this article, a rare case of bilateral popliteal artery entrapment syndrome in a physically active 33-year-old man precipitated by competitive Bicycle Moto-Cross riding is presented. A higher index of suspicion for popliteal artery entrapment syndrome is recommended as the underlying pathology in a young active person with symptoms of lower limb claudication. Popliteal artery entrapment syndrome should be investigated with thorough radiological assessment prior to any therapeutic intervention, which is often fraught with difficulty due to chronically diseased vasculature and inherent anatomical anomalies.

Shaft Aneurysm of Femoropopliteal Expanded Polytetrafluoroethylene Graft Treated With a Covered Stent

2008-08-26

Aneurysm formation is a known complication of native vein or synthetic grafts following peripheral bypass surgery. However, with improvement in the material used for prosthetic grafts, these complications are now uncommon. Open surgery has always been the treatment of choice for aneurysms, but the emergence of percutaneous endovascular intervention has led to a safer and easier way to treat aneurysms. In this article, a unique case of aneurysm in a reinforced expanded polytetrafluoroethylene graft placed 11 years ago during a femoropopliteal bypass surgery in a 77-year-old woman with peripheral arterial disease is presented. The aneurysm was treated percutaneously with a self-expanding covered stent resulting in complete isolation of the aneurysm with no complications encountered.

A Novel Alternative to Open Conversion for Type 1 Endoleak Resulting in Ruptured Aneurysm

Varcoe, R. L., Laird, M. P., Frawley, J. E. — 2008-08-26

In this article, a novel technique for the treatment of ruptured abdominal aortic aneurysm secondary to proximal type 1 endoleak as a result of progressive neck dilatation after endovascular aneurysm repair is reported. A 74-year-old man with multiple comorbidities including severe ischemic heart disease, congestive cardiac failure, and chronic renal failure presented with a ruptured abdominal aortic aneurysm. He had an infrarenal endovascular aneurysm repair performed in 1999 and had subsequently developed a proximal type 1 endoleak. At open laparotomy, the placement of 4 nylon ties around the infrarenal aneurysm neck to refashion a seal and exclude the sac from systemic pressurization effectively treated the rupture. In the high-risk patient, ruptured proximal type 1 endoleak can be successfully treated with external banding avoiding the potential morbidity seen with the aortic clamping and blood loss of open conversion.

Endovascular Treatment of Aberrant Right Subclavian (Lusorian) Artery to Oesophagus Fistula: A Case Report

2008-08-26

The creation of a fistula between the subclavian artery and the oesophagus is extremely rare. All the reported cases of subclavian oesophagus—arterial fistulae have been described either in aberrant subclavian arteries or as caused by foreign bodies in the oesophagus. In this article, a case of fistulous communication between an aberrant right subclavian and the oesophagus managed with the positioning of endovascular prosthesis is presented.

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

Basic Science Review: The Myopathy of Peripheral Arterial Occlusive Disease: Part 2. Oxidative Stress, Neuropathy, and Shift in Muscle Fiber Type

2008-04-17

In recent years, an increasing number of studies have demonstrated that a myopathy is present, contributes, and, to a certain extent, determines the pathogenesis of peripheral arterial occlusive disease. These works provide evidence that a state of repetitive cycles of exercise-induced ischemia followed by reperfusion at rest operates in patients with peripheral arterial occlusive disease and mediates a large number of structural and metabolic changes in the muscle, resulting in reduced strength and function. The key players in this process appear to be defective mitochondria that, through multilevel failure in their roles as energy, oxygen radical species, and apoptosis regulators, produce and sustain a progressive decline in muscle performance. In this 2-part review, the currently available evidence that characterizes the nature and mechanisms responsible for this myopathy is highlighted. In part 1, the functional and histomorphological characteristics of the myopathy were reviewed, and the main focus was on the biochemistry and bioenergetics of its mitochondriopathy. In part 2, accumulating evidence that oxidative stress related to ischemia reperfusion is probably the major operating mechanism of peripheral arterial occlusive disease myopathy is reviewed. Important new findings of a possible neuropathy and a shift in muscle fiber type are also reviewed. Learning more about these mechanisms will enhance our understanding of the degree to which they are preventable and treatable.

Should Endovascular Repair Be Used for Small Abdominal Aortic Aneurysms?

2008-04-17

The outcomes of endovascular repair for small abdominal aortic aneurysm (4.0-4.9 cm) is reported. All patients undergoing endovascular abdominal aortic aneurysm repair between 2000 and 2006 with maximal diameter 4.0 to 4.9 cm form the small aneurysm study cohort. Data were analyzed retrospectively and life-table methods were used. Of 743 endovascular repairs, 132 (17.8%) were performed for small abdominal aortic aneurysm. Perioperative complication rate was 9.1%. Freedom from aneurysm expansion was 96% at 1 year, 86% at 3 years, and 77% at 5 years. Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively. Perioperative 30-day mortality was 0.8% with an aneurysm-related mortality of 1.5% at 5 years. There were no deaths from delayed aneurysm rupture. Endovascular repair of small abdominal aortic aneurysm is associated with low perioperative morbidity and mortality compared with published results for open repair, and treatment threshold can be reduced to 4 cm in selected patients.

Commentary on "Should Endovascular Repair Be Used for Small Abdominal Aortic Aneurysms?" by Passman et al

Illig, K. A. — 2008-04-17

Markers of Inflammation in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis: A Case-Control Study

Debing, E., Peeters, E., Demanet, C., De Waele, M., Van den Brande, P. — 2008-04-17

Objectives There is evidence that inflammation plays a role in the pathogenesis of atherosclerosis. We compared levels of inflammatory markers between patients undergoing carotid endarterectomy (CEA) and controls, and between patients with symptomatic and asymptomatic internal carotid artery (ICA) stenosis.

Materials and Methods A total of 180 patients with ICA stenosis were compared with 180 age-matched and sex-matched controls. The biomarkers evaluated were high-sensitivity C-reactive protein (hs-CRP), soluble intercellular adhesion molecule 1, soluble vascular cell adhesion molecule 1 (sVCAM-1), and interleukin-6 (IL-6).

Results The levels of hs-CRP, sVCAM-1, and IL-6 in the CEA group were significantly higher than in the control group (1.87 mg/mL vs 1.44 mg/mL, P = .011; 1408 ng/dL vs 672 ng/dL, P < .001; 11.9 pg/mL vs 6.3 pg/mL, P < .001). Multivariate linear regression analysis, adjusted for all clinical and physiologic parameters, showed a significant association between ICA stenosis and hs-CRP, sVCAM-1, and IL-6 concentrations. Analysis of symptomatic (n = 101) and asymptomatic (n = 79) ICA stenosis did not detect a difference in levels of these markers.

Conclusions Our study suggests that inflammatory markers could serve as markers for ICA atherosclerosis but are not useful to identify carotid plaque at risk for symptomatic conversion.

Are Statins an Option in the Management of Abdominal Aortic Aneurysms?

Paraskevas, K. I., Liapis, C. D., Hamilton, G., Mikhailidis, D. P. — 2008-04-17

Medline was searched for studies investigating the perioperative and long-term results that derive from statin use in patients with abdominal aortic aneurysm and the clinical and experimental evidence dealing with aneurysm expansion. Data suggest that statins improve the perioperative and long-term outcomes of aneurysm operations and may also reduce expansion rates. International guidelines recommend the use of statins in these patients because abdominal aortic aneurysms are considered as a coronary heart disease equivalent. These guidelines do not appear to have been widely implemented. Preliminary results suggest that statins might play a role in the management of abdominal aortic aneurysms. Verification of these results in large-scale trials may hold implications for a more comprehensive approach of patients with abdominal aortic aneurysms as well as population-wide aneurysm screening programs. Irrespective of the role of statins on aneurysm expansion rates, it is important to ensure that all abdominal aortic aneurysm patients receive statin therapy to improve perioperative and long-term morbidity and mortality.

Activated Protein C--Protein C Inhibitor Complex in Patients With Abdominal Aortic Aneurysms: Is It Associated With Diameter and Growth Rate?

2008-04-17

Increased thrombin activation was documented in patients with abdominal aortic aneurysm (AAA). Activated protein C—protein C inhibitor (APC—PCI) complex, a new biological marker of thrombin generation, was measured in a population of 232 patients with AAA and a control group, and the association between aneurysm size, growth rate, and APC—PCI was studied. The patients were divided into cohorts according to AAA diameter and compared with a control group. APC—PCI was significantly higher in all AAA cohorts (n = 232; median, 0.36 µg/L; 10th to 90th percentile, 0.18-1.01) compared with the control group (n = 41; median, 0.19 µg/L; 10th to 90th percentile, 0.11-0.31; P ≤ .001). APC—PCI correlated with AAA diameter (r = .22; P = .001), body mass index (r = –.19; P = .004), and age (r = .19; P = .004). APC—PCI did not correlate with AAA growth rate (r = .11; P = .14).

Endovenous Laser Treatment of Saphenous Vein Reflux: How Much Energy Do We Need to Prevent Recanalizations?

Vuylsteke, M., Liekens, K., Moons, P., Mordon, S. — 2008-04-17

The aim of this study was to report the results of high-energy endovenous laser treatment to measure the relationship between the fluence and the outcome in terms of recanalization. In 97 patients, 129 great saphenous veins were treated with endovenous laser treatment, using a 980-nm diode laser. Follow-up visits were done at 3 days, 1 month, and 6 months. The best results were noted 1 month postoperative, but at 6 months, control late recanalizations occured decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to the outcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm² mean fluence in the occlusion group and 43.7 J/cm² in the nonocclusion group. This was a statistical significant difference (P < .01). The occlusion rate on long term is fluence dependent. But recanalizations might occur even in these higher fluence treatment groups. A fluence of 52J/cm² is advised.

Expected Flow Parameters Within Hemodialysis Access and Selection for Remedial Intervention of Nonmaturing Conduits

Back, M. R., Maynard, M., Winkler, A., Bandyk, D. F. — 2008-04-17

Background Persistent poor patency rates of arteriovenous fistulae and bridge grafts for dialysis access prompted us to investigate whether flow parameters derived from an initial postconstruction, precannulation duplex study could predict access longevity or direct remedial procedures to salvage nonmaturing conduits.

Methods We analyzed 125 consecutive dialysis access conduits (34 forearm fistulae, 53 arm fistulae, 38 prosthetic bridge grafts, 108 patients, 82 male/26 female, average age 58 years) over the past 5 years having early (2 to 8 weeks) duplex scanning done prior to attempted hemodialysis cannulation. Velocity waveforms were recorded in the arterial inflow, arterial and venous anastomoses, mid-conduit, and in the venous outflow with averaging of volume flow rate (product of average velocity and cross-sectional area) measured at 3 mid-conduit sites. Conduits were deemed "adequate" for dialysis cannulation or "nonmaturing" by the presence of detected high-grade stenoses (peak systolic velocity >400cm/s, velocity ratio >3, and minimal diameter <2 to 3 mm) and subjected to remedial interventions (endovascular or open). Subsequent access function for hemodialysis use and late patency were recorded and correlated with early duplex findings.

Results Average flow rates (forearm fistula 784 ± 623 mL/min, arm fistula 1400 ± 850, bridge graft 1270 ± 604) and mid-conduit peak-systolic velocities (215 ± 214 cm/s forearm fistula vs 312 ± 194 arm fistula) differed between conduit type and location. Remedial interventions were needed in 10 (26%) bridge grafts and 18 (21%) fistulae "nonmaturing" due to occlusive lesions. Conduit flow rates differentiated "nonmaturing" (606 ± 769 mL/min) and "maturing" (1140 ± 857) fistulae (P = .01). A threshold conduit flow rate of 800 mL/min better discriminated failing and functional fistulae and bridge grafts (accuracy 77%) than a flow rate greater or less than 500 mL/min (accuracy 67%). Remedial interventions doubled average flow rates of "nonmaturing" accesses (from 605 to 1159 mL/min) to values similar to "mature, functional" conduits (1374 mL/min) and facilitated a mean duration of patency (12.9 months) equivalent to conduits not needing remedial interventions (11.5 months).

Conclusions Duplex-derived hemodynamic parameters characterized early dialysis access conduit function, prognosticated access patency, guided necessary remedial interventions, and facilitated favorable access longevity.

Popliteal Artery Aneurysm Surgery: The Role of Emergency Setting

2008-04-17

The aim of this study was to compare the outcomes of emergent surgery caused by acute complications versus elective surgery of popliteal artery aneurysms (PAAs) and to evaluate the advantages of elective repair related to limb salvage and bypass patency rates. Fifty PAAs were operated on in 40 patients from January 2000 to December 2004. Surgery was elective in 34 cases (68%) and emergent in 16 (32%). Emergent repair was performed because of acute complications. All patients were treated surgically. Early results in terms of limb salvage, primary patency, and assisted patency were assessed. Follow-up consisted of clinical and/or ultrasonographic examinations at 10 days and 1, 3, 6, and 12 months and yearly thereafter. Long-term limb salvage and bypass patency rates were analyzed. The mean follow-up was 17 months. The 1-year limb salvage rate in the elective group was 97.1% versus 56.3% in the emergent group (P = .0007). The bypass patency rate at 1 year was 94.1% in the elective group versus 66.7% in the emergent group (P = .03). In this study, the outcomes of the PAA repair were significantly better in the group operated electively and without acute symptoms at presentation compared with the group with acute complications, operated on emergently, especially related to limb salvage and bypass patency rates.

Endovascular Retrieval of an Intraaortic Greenfield Vena Cava Filter

Xenos, E. S., Minion, D. J., Sorial, E. E., Endean, E. D. — 2008-04-17

Aberrant placement of vena cava filters has been documented. Only one case of intraaortic deployment, in which the filter was left at the aortic bifurcation with no adverse effects over a 4-year follow-up period, has been reported. We describe the endovascular retrieval of an intraaortic Greenfield filter using a snare and large sheath to protect the aortic intima from injury during removal of the device.

Surgical Complications in a Hemophilia Patient With Factor VIII Inhibitor and Their Endovascular Management

Sadat, U., Naik, J., Hayes, P. D. — 2008-04-17

Hemophilia, an X-linked disorder due to clotting factors VIII or IX deficiency, is associated with recurrent hemorrhage into joints, soft tissue, and organs. Recombinant factor VIII concentrates are available for the treatment of bleeding complications. However, inhibitors to factor VIII develop in 25% to 35% of patients with severe hemophilia A, making the management of bleeding episodes more complex. The treatment of unusual metachronous ruptured aneurysms in a patient with hemophilia A with factor VIII inhibitor is presented, and the outcomes of endovascular and open operations are discussed.

Endovascular Treatment of Ileocolic Pseudoaneurysm After a Laparoscopic-Assisted Bowel Resection for Crohn Disease

Edden, Y., Shussman, N., Cohen, M. J., Verstandig, A., Pikarsky, A. J. — 2008-04-17

Since the introduction of laparoscopic-assisted ileocolic resection for Crohn disease more than 15 years ago, it has become established as a challenging but feasible and safe procedure. A crucial step in the operation is the division of the thick and chronically inflamed mesentery, which in many cases is performed extracorporeally. We report a case of a 32-year-old man with a 14-year history of Crohn ileitis who underwent elective laparoscopic-assisted ileocolic resection. His procedure and the postoperative course were uneventful. A computed tomography scan 2 weeks later revealed a 3-cm-diameter asymptomatic mesenteric pseudoaneurysm, which was successfully treated by transcatheter coil embolization. Pseudoaneurysm of mesenteric arteries has not been documented before in relation to bowel resection by conventional or minimally invasive approaches. It is likely that the thick vascular mesentery of this patient with Crohn disease was a contributing factor to this complication.

Endovascular Repair of Femoral Artery Pseudoaneurysm After Orthopedic Surgery With Balloon-Expandable Covered Stents

Eslami, M. H., Silvia, B. A. — 2008-04-17

Arterial injury after orthopedic procedures is an uncommon complication that can present clinically in a variety of forms and has conventionally been repaired by open vascular surgery. The case and discussion in this article highlights the usefulness of endovascular repair following a delayed presentation of vascular injury from an orthopedic procedure.

Surgical Repair of a Gunshot Injury to the Left Carotid Artery: Case Report and Review of Literature

Kropman, R. H. J., de Vries, J.-P. P. M., Segers, M. J. M. — 2008-04-17

We present a case of a 37-year-old man who sustained a single gunshot wound (penetrating zones I and II) and internal carotid artery injury. Optimal evaluation and management of vascular injury remains controversial. Literature on the operative techniques of carotid artery injuries is reviewed.

Endovascular Exclusion of Superior Mesenteric Artery Pseudoaneurysms: An Alternative to Open Laparotomy in High-Risk Patients

Jimenez, J. C., Lawrence, P. F., Reil, T. D. — 2008-04-17

Superior mesenteric artery (SMA) aneurysms are rare. However, patients are frequently symptomatic on presentation and require urgent repair. SMA aneurysms have the potential for severe complications, including thrombosis or rupture, resulting in acute mesenteric ischemia and death. In patients with adhesions secondary to prior abdominal surgery, traditional open exposure of the aneurysm neck via dissection at the base of the transverse colon mesentery may be technically difficult. Endovascular exclusion of visceral artery aneurysms using covered stent grafts presents a reasonable alternative to the morbidity associated with laparotomy. We report an interesting case of a patient with a large SMA aneurysm and multiple prior laparotomies treated percutaneously with a combined expanded polytetrafluoroethylene/nitinol self-expanding stent-graft allowing maintenance of end-organ perfusion and bowel viability.

Prolonged Success With a Covered Endovascular Stent After Emergent Use in Radiation-Induced Subclavian Artery Blowout: A Case Report

Ewings, E. L., Wittgen, C. M., Paletta, C. E. — 2008-04-17

Radiation-induced damage to the bone, soft tissues, and vasculature represents the unfortunate consequences of radiation therapy for the treatment of malignant tumors. Complications arising from irradiation are frequently challenging to manage and may be life threatening. A case is presented of a patient with a longstanding clavicular osteoradionecrosis with an acute massive hemorrhage after rupture of the subclavian artery and subsequent management with endovascular stent placement. With over 2 years' follow-up, vascular patency was maintained with no further bleeding episodes in this surgically high-risk patient.

Interposition Grafting of Popliteal Artery Cystic Adventitial Disease: Case Report

Patel, S. M., Patil, V. A., Pamoukian, V. N. — 2008-04-17

Cystic adventitial disease of the popliteal artery is a rare cause of leg claudication occurring primarily in young adults. We report a case of a 41-year-old athletic man who presented with rapidly progressive left leg claudication. Using duplex ultrasound and magnetic resonance angiography, a diagnosis of popliteal artery cystic adventitial disease was made. The cystic popliteal artery was resected and replaced using a prosthetic interposition graft. At the 1.5-year follow-up, the cysts have recurred; however, the related symptoms have not. This is in contrast to a previously reported case of interposition saphenous vein grafting requiring resection due to invasion by recurrent cysts within 6 months.

Platelet Activation in Bypass Surgery for Critical Limb Ischemia

Dalainas, I. — 2008-04-17

Book Review: Schillinger M, Minar E (eds). Complications in Peripheral Vascular Interventions. London: Informa UK Ltd; 2007. (229 pp, $95.00)

Jacobs, C. — 2008-04-17

Prospective Randomized Trials of Carotid Artery Stenting Versus Carotid Endarterectomy: An Appraisal of the Current Literature

Lin, P. H., Barshes, N. R., Annambhotla, S., Huynh, T. T. — 2008-01-31

Carotid artery stenting has emerged as a treatment alternative in patients at high risk for carotid endarterectomy. Recent technological advances in catheter-based intervention have both facilitated the procedure and possibly improved the clinical outcome of this percutaneous intervention. The reduction in device profile of introducer sheaths and stents, as well as the ubiquitous use of neuroprotection devices, has resulted in a greater application of this treatment modality in patients with carotid bifurcation disease. The efficacy of carotid artery stenting must be carefully evaluated against carotid endarterectomy in a prospective randomized manner, as the latter treatment has long been considered the standard treatment of carotid occlusive disease. Several recent clinical trials comparing carotid artery stenting versus carotid endarterectomy have yielded mixed results with regard to the efficacy of this percutaneous intervention. This article analyzed the results of these prospective randomized trials comparing carotid artery stenting and carotid endarterectomy. Critical appraisal of these trials, as well as relevant methodological issues of these investigations, is discussed in this article.

A Population-Level Analysis: The Influence of Hospital Type on Trends in Use and Outcomes of Lower Extremity Angioplasty

Vogel, T. R., Symons, R. G., Flum, D. R. — 2008-01-31

Objective The use of infrainguinal percutaneous transluminal angioplasty (PTA) has increased, but patterns of use have not been well studied. Academic institutions (AIs) and nonacademic institutions (NAIs) may have developed different practice patterns and may have different associated outcomes.

Methods A retrospective statewide population-based administrative database was evaluated for patients undergoing PTA (1997-2004).

Results A total of 1718 patients underwent PTA for claudication (51.9%), rest pain (12.1%), and ulceration or gangrene (23.1%). The use of infrainguinal stents (62.4% vs 60.8%), elective procedures (76.3% vs 79.8%), in-hospital death (1.6% vs 2.2%), 30-day mortality (2.1% vs 3.3%), readmission rates (17.1% vs 15.9%), and reintervention rates after readmission (38.5% vs 42.9%) were similar between groups. Increased use of PTA was noted in AIs versus NAIs (239.5% vs 53.9%). AIs were significantly less likely to perform PTA for rest pain (7.5% vs 14.4%, P < .05).

Conclusion AIs had a more recent increase in the use of PTA, but less often used PTA for patients with rest pain compared with NAIs. Both center types had higher than expected 30-day readmission and reintervention rates. Further understanding of the implementation and associated outcomes of PTA is required.

The Incidence of Unplanned Returns to the Operating Room After Peripheral Arterial Bypass Surgery and Its Value as Indicator of Quality of Care

Ploeg, A. J., Lange, C. P. E., Lardenoye, J.-W., Breslau, P. J. — 2008-01-31

Background In recent years, a growing need has arisen to define possible indicators of quality of care.

Methods To examine whether unplanned return to the operating room within 30 days after the initial procedure could serve as an indicator to assess quality of care in peripheral arterial bypass surgery, all bypass procedures performed between January 1996 and January 2004 were evaluated. Data were obtained from a prospectively kept hospital registration system.

Results A total of 607 consecutive procedures were performed in 468 patients. The overall unexpected return to the operating room rate was 11.2%. Patients requiring peripheral arterial bypass surgery for critical ischemia with gangrene were significantly more at risk for an unplanned reoperation (20.2%) than patients with disabling claudication (2.1%) (P < .0001). Patients requiring femorocrural bypass surgery (24.2%) were also more at risk than patients with a suprageniculate bypass procedure (5.2%) (P < .0001).

Conclusions Unplanned return to the operating room within 30 days after the initial operation can be a useful indicator of quality of care after peripheral arterial bypass surgery. However, a prospective, well-defined registration system to collect all data is essential. Furthermore, the severity of peripheral arterial disease and the type of procedure performed should be taken into account.

Dynamic Cine-Computed Tomography Angiography Imaging of Standard and Fenestrated Endografts: Differing Effects on Renal Artery Motion

2008-01-31

Different endograft configurations (fenestrated, transrenal, infrarenal) may varyingly affect aortic side branch movement. Renal artery motion was evaluated with 64-slice dynamic cine-computed tomography angiography before and after endovascular aneurysm repair in 16 patients (46 renal arteries). Center-of-mass displacement of the renals was determined per heartbeat for before repair for 3 different endografts; differences were compared, with significance at P < 0.5. Preoperative renal artery motion is significant (1.2 [SD 0.5] mm, range, 0.6-2.). Neither transrenal nor infrarenal endografts alter renal artery motion compared with before repair (P < .05). Renal artery motion after fenestrated endovascular repair with renal stents reduces motion to 25% of the preoperative value (0.3 [SD, 0.1] mm, range, 0.2-0.5 mm; P = .01). Endograft implantation without stented side branches does not change renal artery motion, potentially allowing significant movement of the renal artery relative to the fenestration. Routine stenting of fenestrations limits postoperative renal artery motion to 0.3 mm, thereby preventing significant branch movement in relation the fenestration.

Implementation of the Continuous AutoTransfusion System (C.A.T.S) in Open Abdominal Aortic Aneurysm Repair: An Observational Comparative Cohort Study

Tawfick, W. A., O'Connor, M., Hynes, N., Sultan, S. — 2008-01-31

The use of the Continuous AutoTransfusion System (C.A.T.S; Fresenius Hemotechnology, Bad Homburg v.d.H., Germany), which conserves allogenic blood, is reported in 187 patients having abdominal aortic aneurysm repair during a 9-year period. Patients were allocated to C.A.T.S if a Haemovigilance technician was available. A mean of 685 mL of retrieved blood was reinfused in 101 patients receiving C.A.T.S; 61% required 2 U or less. All control patients required 3 U or more of allogenic blood. Allogenic transfusion in C.A.T.S patients decreased significantly (P < .0001). Mean intensive care unit stay was significantly reduced in C.A.T.S patients (P = .042). Mean postoperative hospital stay was 18 days for C.A.T.S group and 25 days in control patients (P = .014). The respective 30-day mortality was 12% versus 19% (P = .199). The C.A.T.S markedly reduced the amount of blood transfused, was associated with reduced intensive care unit and postoperative hospital stay, and was cost-effective.

Serum Creatinine Stabilization Following Renal Artery Stenting

Bates, M. C., Campbell, J. E., Broce, M., Lavigne, P. S., Riley, M. A. — 2008-01-31

The impact of renal artery stenting on renal function in a subgroup of consecutive de novo patients with atherosclerotic renal artery stenosis from the single operator, single center, retrospective renal stent trial is defined. Patients with inadequate preprocedure and/or follow-up renal function studies were excluded. Abnormal baseline serum creatinine (sCr) was defined as ≥1.5 mg/dL. Follow-up sCr was improved, unchanged, or worsened if the variance from baseline decreased by >20%, stayed within 20%, or increased >20%, respectively. For the total cohort (194 patients), renal function stabilized or improved in 72% of patients. Plotting 1/sCr demonstrated a decline in renal function before the procedure that stabilized following renal artery stenting. Bilateral renal artery stenting predicted normal follow-up sCr, and baseline sCr >2.1 mg/dL was associated with improvement in sCr long-term. In conclusion, renal artery stenting results in overall stabilization of renal function, and bilateral renal artery stenting seems to have added benefit.

A Global Assessment of the Inflammatory Response Elicited Upon Open Abdominal Aortic Aneurysm Repair

2008-01-31

The inflammatory response during elective open infrarenal abdominal aortic aneurysm repair and its impact on outcome is investigated. Twenty high-risk patients were enrolled, and blood samples were obtained at 8 perioperative time points. Endotoxin, cytokines (tumor necrosis factor- and interleukin-1β, and interleukin-6), CD11b expression, and nitric oxide were measured. Peak endotoxin levels occurred within 30 minutes of reperfusion and were higher among patients developing complications. Interleukin-6 levels increased during reperfusion, reaching a peak on the first postoperative day. Interleukin-6 increase correlated with aortic clamp time and morbidity. CD11b expression increased 30 minutes after reperfusion, and this effect was greater among patients who developed complications. Endotoxin may be important in the pathogenesis of multiple organ dysfunction syndrome. Activated neutrophils may have a central role in tissue injury after reperfusion. Intraoperative CD11b upregulation may be an early marker for postoperative complications after infrarenal abdominal aortic aneurysm repair.

Endovascular Repair of a Common Iliac Artery Aneurysm Using the Cook Zenith Abdominal Aortic Aneurysm Endovascular Graft Converter

Crago, A. M., Singh, N., Deaton, D. H., Neville, R. F., Laredo, J. — 2008-01-31

Isolated common iliac artery aneurysm is a rare condition that is treated aggressively because of its high risk of rupture. Endovascular abdominal aortic aneurysm (AAA) repair has recently been extended to the clinical management of the iliac artery aneurysm. Stent grafts have been used successfully to exclude iliac artery aneurysms. Successful graft deployment and aneurysm exclusion require adequate seal and fixation at the proximal and distal attachment sites. This article presents a high-risk surgical patient whose 6.8-cm-diameter iliac artery aneurysm was repaired with a Zenith AAA Endovascular Graft Converter (Cook, Bloomington, Indiana). This device is normally used to convert an aortobiiliac endograft to an aortouniiliac endograft during AAA repair. The tapered 80-mm-long graft has diameters of 24 mm proximally and 12 mm distally. Completion arteriogram demonstrated exclusion of the iliac artery aneurysm with no evidence of endoleak. No postoperative complications occurred. No endoleak was seen on the follow-up abdominal computed tomography scan.

Surgical Management of Deep Venous Insufficiency Caused by Congenital Absence of the Infrarenal Inferior Vena Cava

Arash Mohammadi Tofigh, , Coscas, R., Koskas, F., Kieffer, E. — 2008-01-31

Congenital absence of the inferior vena cava (CAIVC) is a rare vascular defect, commonly reported as a fortuitous finding because patients are typically asymptomatic of the condition itself but are symptomatic of associated conditions such as congenital heart disease, polysplenia, asplenia, and inversion of bowel viscera. The presence of CAIVC is probably underestimated because CAIVC may not be detected by compression B-mode ultrasonography. By use of computed tomography, we diagnosed a case of CAIVC in a young athletic patient with disabling venous stasis symptoms of the lower limbs. Venous prosthetic reconstruction of the infrarenal vena cava provided with early subsiding of edema and healing of stasis ulcers. An intracaval web was found as potentially responsible for the condition. We present and propose our surgical method for this rare disabling condition.

Medical Management of Spontaneous Celiac Artery Dissection: Case Report and Literature Review

Poylin, V., Hile, C., Campbell, D. — 2008-01-31

Spontaneous visceral artery dissections are a rare occurrence. Here we report a case of spontaneous celiac artery dissection that was treated without surgery.

Pseudoaneurysm of the Brachial Artery Following Humeral Fracture

Moran, D., Roche-Nagle, G., Ryan, R., Brophy, D., Quinlan, W., Barry, M. — 2008-01-31

The frequency of peripheral artery aneurysms in the upper extremities is less than in the lower extremities. Diagnosis and surgical treatment are important because upper extremity aneurysms can severely compromise the function of a limb and possibly lead to the loss of an arm or fingers. Very rarely, posttraumatic upper extremity pseudoaneurysms show symptoms after a long period of time. Diagnosis can be made on review of the patient's history and a physical examination. Surgical reconstruction is the preferred treatment for such patients. We present a case of a brachial artery pseudoaneurysm following humeral fracture.

"Unpredictable" Late Rupture of an Abdominal Aortic Aneurysm After Bifurcated Ancure Endograft Repair

Rosen, N. A., Cayne, N. S., Macari, M., Jacobowitz, G. R. — 2008-01-31

The goal of endovascular repair of an abdominal aortic aneurysm is to exclude the aneurysm from systemic arterial pressure, thereby preventing rupture. However, the long-term durability of endovascular repair continues to be in question, as aneurysm rupture after endovascular repair continues to be reported. We report the case of an 89-year-old patient who underwent endovascular repair of a 7.1-cm abdominal aortic aneurysm with an Ancure endograft 5 years earlier. Despite close follow-up and a shrinking aneurysm sac on annual contrast-enhanced computed tomography, he presented with aneurysm rupture and a new proximal type I endoleak. The endoleak and rupture were successfully repaired with endovascular placement of a main body extension.

Use of Cryopreserved Femoral Vein for In Situ Replacement of Infected Femorofemoral Prosthetic Artery Bypass

Dosluoglu, H. H., Kittredge, J., Cherr, G. S. — 2008-01-31

Isolated groin infection following crossover femoral bypass is not uncommon, and its management may be challenging, especially in medically high-risk patients. When an in situ replacement is appropriate, using an autologous vein (femoral or saphenous) would be the preferred method; however, this may not always be feasible. The authors used cryopreserved femoral vein grafts for in situ replacement of femorofemoral bypass grafts with excellent results in 3 high-risk patients who developed early graft infections and failed graft preservation attempts. In situ replacement of infected femorofemoral grafts using a cryopreserved femoral vein graft can be considered as a second-line intervention when an adequately sized autologous vein is unavailable or unusable or is not feasible in high-risk patients.

Superior Mesenteric Artery Stent Fracture Producing Stenosis and Recurrent Chronic Mesenteric Ischemia: Case Report

Klepczyk, L., Keeling, W. B., Stone, P. A., Shames, M. L. — 2008-01-31

Endovascular modalities are being increasingly employed in the treatment of a variety of vascular diseases. With new technologies come novel complications, and one such complication unique to endovascular surgery is stent fracture. We present two cases of stent fracture following stenting of the superior mesenteric artery and discuss possible causes and treatments.

Should Patients With Contained Rupture of a Descending Aortic Aneurysm Only Receive Unilateral Artificial Ventilation? Case Report of a Death During an Operation

Hofmann, H.-S., Kroll, H., Kunze, C., Bromber, H. — 2008-01-31

The danger of thoracic aneurysm rupture increases with the size of the aneurysm. We report on a 59-year-old man who developed a secondary aneurysm of the descending thoracic aorta within the residual type A dissection that was approximately 9-cm long and in which a contained rupture occurred. The patient died as a result of a massive hemorrhage during the anesthesiological preparation for emergency operation a short time after double-lumen intubation and commencement of controlled artificial ventilation. Autopsy revealed an atelectatic lower pulmonary lobe that had partially fused with the aneurysm. The fusion may have been so substantial that it may have acutely eliminated the covering of the contained rupture during artificial ventilation.

Acute Lower Extremity Ischemia Secondary to Salivary Gland Tumor Embolus

Bottoni, D. A., Franklin, J. H., Forbes, T. L. — 2008-01-31

Malignant arterial tumor emboli of sufficient size that is capable of causing organ infarction or ischemia are exceedingly rare. The majority of these emboli are associated with either primary or secondary pulmonary malignancies and commonly occur perioperatively or immediately postoperatively. This study describes an unusual case of acute lower extremity ischemia secondary to a malignant parotid tumor embolus with evidence of left ventricular involvement.

Physician as Hospital Chief Executive Officer

Falcone, R. E., Satiani, B. — 2008-01-31

The vast majority of hospitals in the United States today are led by nonphysicians. This is in sharp contrast to the turn of the 20th century, when over a third of the hospitals in the United States were physician led. As the pendulum swings back from lay leader to clinician leader, there is a strong and appropriate opportunity for physicians to reinsert themselves into a leadership role. In fact, the time has perhaps never been more appropriate than today. In a health care system that is complex, troubled, and challenging, the physician CEO brings a unique set of skills to the business of medicine. The successful physician leader, however, must understand the business of medicine as well as or better than he or she understands the practice of medicine. Training, developing, and equipping our future physician leaders with the necessary skill sets will be one of medicines' many challenges as it expands into the 21st century.