Vascular and Endovascular Surgery recent issues

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.

Basic Science Review: Vascular Distensibility as a Predictive Tool in the Management of Small Asymptomatic Abdominal Aortic Aneurysms

Hoegh, A., Lindholt, J. S. — Tue, 25 Aug 2009 04:16:57 PDT

Background: This study investigates whether baseline aortic wall distensibility serves as a supplemental bio-marker for AAA progression and need for later repair. Methods: In 1998, 61 males with a small asymptomatic AAAs had a baseline measurement of elasticity and stiffness, using an echo-tracking ultrasound system (Diamove). The cohort was followed till 2005 concerning Dmax, expansion rate, operations for AAA, hospitalisation do to cardiovascular disease and death. Results: During follow-up, 49% died, and 45.9% were hospitalised do to cardiovascular disease, compared to Dmax, Ep and b no significant associations were found. Elasticity correlated moderately to annual expansion rate and Dmax. Good correlation was found between annual expansion rate and Dmax. ROC-curve analysis showed that elasticity, stiffness and Dmax all tended to predict future need for AAA-repair. Conclusion: Baseline aortic wall distensibility may provide an additional parameter for AAA to optimize the indication and time for elective repair.

Effect of Hospital Volume on In-Hospital Mortality for Renal Artery Bypass

Tue, 25 Aug 2009 04:16:57 PDT

Background: A recent report determined that the nationwide mortality for renal artery bypass (RAB) is surprisingly high—10%. We hypothesized that operative mortality for RAB is related to the volume of such operations performed in each center. Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing RAB for the years 2000-2005. In-hospital mortality for RAB was compared between hospitals. Results: During the study period, RAB was performed on 7413 patients with an overall in-hospital mortality of 9.6%. The multivariate logistic regression analyses revealed that after adjusting for surgical risk, increasing hospital volume was significantly associated with decreased in-hospital mortality for RAB (odds ratio 0.98; 95% confidence interval, 0.96-0.99; P = .015). Conclusions: Patient risk profile and hospital volume are critical determinants of in-hospital mortality for RAB, which should be factored into decision making for patients requiring intervention for renovascular disease.

Is Balloon Angioplasty of Peri-Anastomotic Stenoses of Failing Peripheral Arterial Bypasses Worthwhile?

Tue, 25 Aug 2009 04:16:57 PDT

Introduction: Surgical revision of failing peripheral arterial bypass grafts has generally been shown to provide superior patency rates compared to balloon angioplasty. We analyzed whether balloon angioplasty, specifically of peri-anastomotic stenoses (PAS), provided acceptable patency rates, because surgery for these lesions is more difficult and is likely associated with higher complication rates compared to surgical revision of stenoses in the body of a graft. Methods: This is a retrospective review of PAS balloon angioplasties performed at a single institution between January 1, 1999, and September 1, 2005. We report ‘‘primary site patency’’ as a stenosis treated by balloon angioplasty, ‘‘revised primary site patency’’ as a stenosis treated by repeat balloon angioplasty, and ‘‘secondary site patency’’ as an angioplastied stenosis treated surgically or when the graft thrombosed and was revised surgically. All procedures were performed in an endovascular operating room based on duplex scan findings suggesting a significant stenosis. Results: 48 PAS in 33 autologous vein and 15 prosthetic grafts were treated by balloon angioplasty in 42 patients. Mean follow-up was 12 months (range, 1-49 months). Interventions were performed on 22 femoropopliteal grafts (11 proximal, 11 distal), 20 femorotibial grafts (5 proximal, 15 distal), 2 axillofemoral grafts (2 proximal anastomoses), 2 popliteal-pedal grafts (1 proximal, 1 distal), and 1 common iliac-femoral graft (proximal). Life-table analysis revealed 2-year primary, assisted primary, and secondary patency rates of 38%, 58%, and 84%, respectively. No major complications occurred with any endovascular intervention. Conclusion: Balloon angioplasty of PAS resulted in acceptable 2-year assisted primary patency rate of almost 60%. Endovascular intervention avoided repeat incisions in scarred groins, higher rates of nerve injury and infection, significant blood loss, and longer length of hospital stays. We recommend that balloon angioplasty of PAS be attempted before resorting to surgical intervention, especially in cases of hostile anastomotic wounds.

Intraoperative Endoleak During EVAR: Frequency, Nature, and Significance

Tue, 25 Aug 2009 04:16:57 PDT

Objective: Endoleaks are critical complications of endovascular abdominal aortic aneurysm repair (EVAR). This study sought to determine the frequency and nature of intraoperative endoleaks and their impact on postoperative endoleak-related events. Methods: A retrospective chart review was performed of all patients who underwent EVAR at our institution. The impact of intraoperative endoleaks on postoperative endoleak rates and endoleak-related reintervention rates were assessed. Results: From December 18, 1996, to May 21, 2003, 241 patients underwent EVAR. An endoleak was observed during 126 (52.3%) procedures. Type I endoleaks were observed in 63 (26.1%) cases: 35 proximal and 31 distal endoleaks (3 cases at both attachments). Angioplasty, additional cuff placement, or stenting corrected 59 (89.4%) of these endoleaks. A total of 71 type II intraoperative endoleaks (29.5%) and 8 type IV endoleaks (3.3%) were observed without any attempted corrective maneuvers. Ten type III endoleaks (4.2%) occurred but all resolved with angioplasty or additional cuff placement. In all, 86 (35.7%) endoleaks persisted on completion angiogram. Patients with a type I or type II intraoperative endoleak were more likely to have an endoleak at 1.5 years (31.4% vs. 21.6%, P = .018). Reinterventions were required more often after an intraoperative type I endoleak (10% vs. 4%, P = .003). Patients with intraoperative endoleaks demonstrated a trend toward less postoperative aneurysm diameter reduction at 2 years (43.8% vs. 74.5%, P = .104). Conclusion: The presence of a type I or a type II endoleak during EVAR significantly increases the likelihood of a postoperative endoleak and should prompt a high degree of suspicion during follow-up.

Inflammatory Abdominal Aortic Aneurysms (IAAA): Past and Present

Tue, 25 Aug 2009 04:16:57 PDT

Aim: The aim of the study is to determine whether presentation and outcomes of inflammatory abdominal aortic aneurysms (IAAA) have changed over the last five decades. Methods: Comparison of current outcomes (January 2001 to December 2007) with results of the earliest report from our unit in 1972. Results: In contemporary series, 421 patients underwent AAA repair; 38 (9%) were IAAA. In 58% patients, IAAA was an incidental finding, whereas 42% patients were symptomatic with abdominal or back pain. Of those, 32% were ruptured IAAA. Male-to-female ratio was 12:1. Thirty-day mortality was 13%; elective 11.5%; emergency 17%. Comparison with 1972 study showed no change in the incidence and gender predilection. Presentation as an incidental finding and rupture increased 4- and 2-folds, respectively. Conclusion: The incidence and gender predilection of IAAA have remained unchanged. The 4-fold increase in the presentation as an incidental finding reflects current trends in patient evaluation.

Outcome of Carotid Endarterectomy for Acute Neurological Deficit

Tue, 25 Aug 2009 04:16:57 PDT

We reviewed our experience with urgent carotid intervention in the setting of acute neurological deficits. Between June 1992 and August 2008, a total of 3145 carotid endarterectomies (CEA) were performed. Twenty-seven patients (<1.0%) were categorized as urgent. The mean age was 74.1 years (range 56-93 years) with 16 (60%) men, and 11 (40%) women, Symptoms included extremity weakness or paralysis (n = 13), amaurosis fugax (n = 6), speech difficulty (n = 2), and syncope, (n = 3). Three patients exhibited a combination of these symptoms. Three open thrombectomy were performed. Regional anesthesia was used in 13 patients (52%). Seventeen patients (67%), required shunt placement. At 30-days, 2 patient (7%) suffered a stroke, and 1 (4%) died. Urgent CEA can be performed safely. A stroke rate of 7% is acceptable in those who may otherwise suffer a dismal outcome without intervention.

Excimer Laser for Debulking and Lysing Chronic Venous Thrombi and Occlusions

Moritz, M. W., Ombrellino, M., Agis, H. — Tue, 25 Aug 2009 04:16:57 PDT

Lysis of deep venous thrombotic obstruction in the extremities has been shown to decrease the frequency and severity of symptoms of postthrombotic syndrome. However, for those lesions that contain organized thrombus, the use of conventional methods to lyse thrombus is less successful than for acute thrombus. The authors here present a novel method for treatment of older, organized thrombus using excimer laser. This technique can obviate some of the limitations of the other methods and allow effective treatment when other methods fail. It has been used successfully in 19 patients with excellent results and is recommended for those cases.

Carotid Artery Pseudo-occlusion: Does End-diastolic Velocity Suggest Need for Treatment?

Tue, 25 Aug 2009 04:16:57 PDT

Objective: We reviewed our institution’s experience with carotid artery pseudo-occlusion (CAPO), to investigate whether internal carotid artery (ICA) end-diastolic velocity (EDV) as measured by duplex ultrasonography, was a predictor of need for further intervention. Methods: From February 2003 to January 2008, 7478 patients underwent duplex ultrasonographic evaluation of their carotid arteries. Diagnosis of CAPO included the appearance of a narrow flow jet (string sign) on power doppler images, low velocities in the ICA and additional criteria listed below. Results: Ten patients (0.13%) were identified as having a CAPO. All patients were asymptomatic and had an EDV < 78cm/s. Occlusion or functional occlusion was identified in nine patients on contrast imaging studies. Eight of these patients were treated medically without neurologic complication on follow-up. Two patients were treated with interventions and were asymptomatic at follow up. The mean follow up for the entire group was 12 months. Conclusions: Although this is a low volume study, there is evidence to suggest that asymptomatic patients with low EDV in the setting of carotid artery pseudo-occlusion found of duplex, may be safely managed medically.

Transabdominal Duplex Ultrasonography for Bedside Inferior Vena Cava Filter Placement: Examples, Technique, and Review

Amankwah, K. S., Seymour, K., Costanza, M., Berger, J., Gahtan, V. — Tue, 25 Aug 2009 04:16:58 PDT

Pulmonary embolism remains an endemic challenge for public health care. The first line of treatment for venous thromboembolic disorder has been anticoagulation; however, in the absence of appropriate pharmacologic treatment, because of failure or contraindication, caval filter placement has been widely performed in the prevention of pulmonary embolism. Initially an open surgical procedure, technological advancements have allowed filter placement to be done percutaneously. Bedside filter placement in the intensive care unit with ultrasonographic imaging has been reported to be safe, effective, and reliable. In this report, we present an example, discuss our technique, and review the literature.

Renal-Splanchnic Steal Syndrome: The Treatment of Chronic Mesenteric Ischemia With Renal Angioplasty and Stenting

Joseph deFreitas, D., Stoner, M., Powell, S., Parker, F. — Tue, 25 Aug 2009 04:16:58 PDT

The clinical syndrome of chronic mesenteric ischemia classically presents with a combination of involuntary weight loss, post prandial abdominal pain, and food fear. With occlusion or stenosis of the celiac and superior mesenteric arteries (SMA) collateral blood flow between mesenteric vessels is common and frequently act as the sole blood supply to the intestine. We present a rare case of chronic mesenteric ischemia in which the main blood supply to the celiac and SMA were collaterals coming off the right renal artery resulting in renal-splachnic steal. After an unsuccessful attempt to cannulate the SMA and celiac vessels it was possible to relieve this patient’s symptoms with renal artery stenting.

Novel Approach to a Type I Endoleak Following a Hybrid Repair of an Arch Aortic Aneurysm

Barnett, B. P., Qazi, U., Perler, B. A., Malas, M. B. — Tue, 25 Aug 2009 04:16:58 PDT

Hybrid surgical and endovascular approaches such as open visceral vessel debranching and subsequent endovascular exclusion of thoracic abdominal aortic aneurysms (TAAA) represents a significant development in treatment of TAAAs. As compared to traditional endovascular aneurysm repair, hybrid repairs commonly have a higher rate of endoleak and other endograft-related complications. In this report, we present a 71 year-old man with significant comorbidities including chronic obstructive pulmonary disease, hypertension and prostate cancer. The patient after undergoing debranching of the thoracic arch followed by endograft repair of an arch aneurysm developed a proximal type I and type II endoleak fed by the previously ligated left subclavian artery. Despite coiling of the left subclavian artery and proximal extension of the endograft, a type I endoleak persisted. Several months after the left subclavian artery was coiled, a catheter was advanced through the coils and beyond the site of ligation directly into the aneurysmal sac. Once in the aneurysmal sac, multiple coils were deployed resulting in successful treatment of the type I endoleak. This report highlights the unique challenges in treating proximal descending thoracic aneurysms and represents the first report of the treatment of a type I endoleak with reaccess through a previously coiled vessel for deployment of embolics directly into the aneurysmal sac.

Thoracic Outlet Syndrome Associated With a Large Cervical Rib

De Martino, R. R., Stone, D. H., Beck, A. W., Walsh, D. B. — Tue, 25 Aug 2009 04:16:58 PDT

This case illustrates the anatomic impact of a large cervical rib as an etiology for thoracic outlet syndrome. Current management remains predicated on astute diagnosis, multidisciplinary therapy including, physical therapy, scalene muscle blockade, and surgical decompression in appropriate cases.

Bilateral Asymmetric Popliteal Entrapment Syndrome Treated With Successful Surgical Decompression and Adjunctive Thrombolysis

Shen, J., Abu-Hamad, G., Makaroun, M. S., Chaer, R. A. — Tue, 25 Aug 2009 04:16:58 PDT

Popliteal artery entrapment syndrome (PAES) is the most common cause of lower leg claudication in patients younger than 50 years. The different types of PAES can result in different rates of arterial damage, leading to aneurysmal degeneration or occlusion. We report a rare case of a young patient presenting with asymmetrical bilateral popliteal artery entrapment. Type III PAES on the right resulted in severe limb ischemia and was treated by division of the accessory tendon and replacement of damaged artery with vein graft. On the left, the medial head of gastrocnemius was resected to release a type I PAES.

Recurrent Cystic Adventitial Disease of the Popliteal Artery: Successful Treatment With Percutaneous Transluminal Angioplasty

Maged, I. M., Kron, I. L., Hagspiel, K. D. — Tue, 25 Aug 2009 04:16:58 PDT

Cystic Adventitial Disease (CAD) is a rare vascular condition that most commonly affects the popliteal artery. Percutaneous transluminal angioplasty (PTA) is generally not considered a valid therapeutic option due to high recurrence rate. We report a case of CAD of the popliteal artery that recurred after surgical cyst enucleation that was successfully treated with PTA. To the best of our knowledge, this is the first case of successful PTA for the treatment of recurrent CAD of the popliteal artery.

Ewing's Sarcoma of the Inferior Vena Cava

Mahmood, A., Cleasby, M., Hubscher, S. G., Khaira, H. S. — Tue, 25 Aug 2009 04:16:58 PDT

Ewing’s sarcoma most commonly arises from bone but may also arise from soft tissues. Sarcoma of the inferior vena cava is a rare entity that requires multimodal therapy including surgical resection and vascular reconstruction. We describe the first reported case of Ewing’s sarcoma of the inferior vena cava.

Newton's Law to the Rescue: Therapeutic Effects of Gravity Aiding the Management of a Migratory Venous Foreign Body--A Case Report

Nesargikar, P. N., Grannell, M., Hinwood, D., Orme, R., Houghton, A. — Tue, 25 Aug 2009 04:16:58 PDT

The management of intravascular metallic foreign bodies (FB) can be difficult and challenging. We report a case of a migrating FB, initially within the femoral vein which subsequently migrated to the intrahepatic venacava. Following a change of posture, the metallic FB moved with gravity against the normal venous blood flow to the left renal vein. It was finally fixed in position in a peripheral branch of the renal vein using an intravascular stent. Employing gravity as a therapeutic intervention and the technique used in isolating the FB has not, to our knowledge, been reported before. A case is described, and the literature is reviewed.

Extracranial Internal Carotid Artery Mycotic Aneurysm: Case Report and Review

O'Connell, J. B., Darcy, S., Reil, T. — Tue, 25 Aug 2009 04:16:58 PDT

Mycotic aneurysms of the internal carotid artery (ICA) are rare and often difficult to diagnose. They can have nonspecific signs and symptoms, an unclear etiology, and can lead to severe morbidity and mortality if left untreated. We present a case of a 47-year-old woman with an apparent mycotic aneurysm of the extracranial ICA associated with Klebsiella pneumonia. We discuss the various clinical findings and radiographic imaging that lead to this unusual diagnosis and the details of our surgical treatment, which included excision of the mycotic aneurysm and reconstruction with a greater saphenous vein interposition graft. We also review the literature on mycotic aneurysms of the ICA, including the radiologic modalities available to diagnose this condition, epidemiology, pathophysiology, and treatment options.

CT Angiography of Renal Arteriovenous Fistulae: A Report of Two Cases

Tue, 25 Aug 2009 04:16:58 PDT

Renal arteriovenous fistulas (AVFs) are rare abnormal communications between the arterial and venous circulations that can be congenital or acquired. We describe the multidetector computed tomography angiography (MDCTA) appearance of 2 cases of renal AVF, one with the cirsoid and one with the aneurysmal subtype, and the impact of these findings on therapeutic decision making and treatment follow-up.

Clinical Controversy Review: The Transformation of Vascular Surgeons to Vascular Specialists: Policy or Necessity?

Avgerinos, E. D., Dalainas, I., Liapis, C. — Mon, 22 Jun 2009 02:24:38 PDT

The wide spreading of vascular diseases along with the emergence of minimally invasive endovascular therapies and modern medical therapies is inevitably bringing many disciplines into play. Although by definition, vascular surgery is the clinical and scientific discipline concerned with the diagnosis, treatment, and prevention of vascular diseases, many more radiologists and a significant number of cardiologists become increasingly involved. The question of which specialist among those qualified should carry out medical treatment, open, and endovascular procedures is still suspended, and a professional competition is pronounced. This article discusses the necessity of a vascular specialist who guides the holistic management of vascular diseases: open surgery, endovascular intervention, and medical therapy. The different characteristics of those intending to offer vascular care, the training curricula, the workforce demands, and the role of vascular centers are analyzed to illustrate the keystone role of vascular surgeons who are currently transforming to vascular specialists.

How Optimal is the Medical Management of Patients Prior to Major Reconstructive Vascular Surgery? The Results of a Cross-sectional Study

Marshall, C., Lin, P. H., Huynh, T. T., Kougias, P. — Mon, 22 Jun 2009 02:24:38 PDT

Background: Risk factor modification is important in patients with vascular disease. Guidelines suggest that this patient population benefits from a medical regimen of antiplatelets, statins, β-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Materials and Methods: The medical regimen of consecutive patients who presented for major vascular surgery intervention over 18 months was examined. Results: Of the 325 patients identified, 176 (54%) were on antiplatelet treatment, 197 (61%) were on a statin, 180 (55%) on β-blockers, and 146 (54%) on ACE inhibitors. A high-risk subset of 94 smokers with known coronary artery disease, hypertension, and hyperlipidemia or diabetes was identified. In this subset, patients were more likely to be on pharmacologic risk factor modification. Conclusions: Despite recommendations, the pharmacologic risk factor modification of patients prior to vascular surgery remains suboptimal. Increased awareness of the problem and active participation of the vascular specialist are essential to improve compliance with established guidelines.

EVAR in Small Versus Large Aneurysms: Does Size Influence Outcome?

Wang, G. J., Carpenter, J. P. — Mon, 22 Jun 2009 02:24:38 PDT

Objective: To determine whether there is a difference in outcome between endovascular repair of abdominal aortic aneurysm (EVAR) of small versus large aneurysms. Methods: A total of 192 patients from the Power-link trial were subdivided into small abdominal aortic aneurysms (AAA; ≤5 cm) and large AAA (>5 cm) groups. Demographics, perioperative morbidity, mortality, overall survival, and freedom from major adverse events, endoleak, aneurysm-related death, migration, and secondary procedures were assessed. Aneurysmal involvement of the iliacs as well as neck length and angulation was compared between groups. Results: Perioperative morbidity (P = 1.000), mortality (P = .4603), and extent of iliac involvement did not differ between groups (P = .2260). The necks in small AAA were longer (P = .0028) and less angulated (P < .0001). There was no difference in overall survival (P = .6066), freedom from major adverse events (P = .7842), endoleak, (P = .1832), migration (P = .5765), aneurysm-related death (P = .4728), or need for secondary procedures (P = .2323). Conclusion: Under controlled conditions of patient and device selection, there is no significant difference in outcome for EVAR of small versus large AAA.

Has the Implementation of EVAR for Ruptured AAA Improved Outcomes?

Vogel, T. R., Dombrovskiy, V. Y., Haser, P. B., Graham, A. M. — Mon, 22 Jun 2009 02:24:38 PDT

Objective: Previous studies have demonstrated improved outcomes with Endovascular Aneurysm Repair (EVAR) for the treatment of ruptured abdominal aortic aneurysms (rAAA). However, these data may not be generalizable to all regions.

Methods: Retrospective cohort study (2001-2005) using state inpatient data.

Results: 5,176 patients underwent repair of AAA. 700 repairs were performed for rAAA (618 [88%] with open surgery (OS) and 82 [12%] with EVAR). Mortality for rAAA was similar for EVAR and OS (45.1% vs. 52.4%, P = 0.21). Lack of insurance (OR = 5.1; 95%CI: 1.7-15.2) was a predictor of mortality. Cost of repair for rAAA was greater for EVAR ($51,339 ± 51,719 vs. $39,967 ± 43,354, P = 0.03) and hospital LOS was similar (14.08 ± 17.97 vs.13.42 ± 18.18; P = 0.8). Conclusion: EVAR did not offer a survival benefit in the state, had a similar hospital LOS, and was significantly more expensive. Further evaluation exploring explanations for inferior outcomes by region are required as EVAR becomes more commonly implemented for rAAA.

Proinflammatory and Anti-inflammatory Cytokine Balance in Patients With Abdominal Aortic Aneurysm and the Impact of Aneurysm Size

Wallinder, J., Bergqvist, D., Henriksson, A. E. — Mon, 22 Jun 2009 02:24:38 PDT

Abdominal aortic aneurysm is a common condition with high mortality due to rupture; however, the condition also is associated with nonaneurysmal cardiovascular mortality. A possible contributing mechanism for the cardiovascular mortality is an imbalance between the proinflammatory and anti-inflammatory systemic response. In the present study, 78 patients with abdominal aortic aneurysm and 41 controls without aneurysm matched by age, gender and smoking habits were investigated. Cytokines such as interleukin-6, interleukin-10, and monocyte chemoattractant protein-1 were measured in plasma. There was significantly higher level of interleukin-6 in patients with AAA compared to controls. The interleukin-6/ interleukin-10 ratio was highest in patients with large compared to small abdominal aortic aneurysm. In conclusion, the present data indicate a proinflammatory response and a proinflammatory to antiinflammatory imbalance in patients with abdominal aortic aneurysm which is dependent by aneurysm size.

Retroperitoneal Repair of Abdominal Aortic Aneurysm Reduces Bowel Dysfunction

Mon, 22 Jun 2009 02:24:38 PDT

Objective: To assess the effect of intestinal manipulation and mesenteric traction on gastro-intestinal function and postoperative recovery in patients undergoing abdominal aortic aneurysm (AAA) repair. Methods: Thirty-five patients undergoing AAA repair were randomised into 3 groups. Group I (n = 11) had repair via retroperitoneal approach while Group II (n = 12) and Group III (n = 12) were repaired via transperitoneal approach with bowel packed within the peritoneal cavity or exteriorised in a bowel bag respectively. Gastric emptying was measured pre-operatively (day 0), day 1 and day 3 using paracetamol absorption test (PAT) and area under curve (P_AUC) was calculated. Intestinal permeability was measured using the Lactulose-Mannitol test. Results: Aneurysm size, operation time and PAT (on day 0 and day 3) were similar in the three groups. On day 1, the P_AUC was significantly higher in Group I, when compared with Group II and Group III (P = .02). Resumption of diet was also significantly earlier in Group I as compared to Group II and Group III. The intestinal permeability was significantly increased in Group II and Group III at day 1 when compared with day 0, with no significant increase in Group I. Retroperitoneal repair was also associated with significantly shorter intensive care unit (P = .04) and hospital stay (P = .047), when compared with the combined transperitoneal repair group (Group II and III). Conclusion: Retroperitoneal AAA repair minimises intestinal dysfunction and may lead to quicker patient recovery when compared to transperitoneal repair.

Hybrid Endovascular Repair of an Aneurysmal Chronic Type B Dissection in a Patient with Marfan Syndrome With an Aberrant Right Subclavian Artery

Cooper, D. G., Markur, S., Walsh, S. R., Cousins, C., Hayes, P. D., Boyle, J. R. — Mon, 22 Jun 2009 02:24:38 PDT

Abnormal aortic arch anatomy is relatively uncommon but most frequently involves an aberrant right subclavian artery. Rarely, it is associated with aneurysmal dilatation of a chronic type B dissection. Under such circumstances, the abnormal anatomy may complicate therapeutics options. Furthermore, controversy exists regarding the use of surgical or endovascular techniques in patients with aortic aneurysms and underlying arteriopathies. The current literature is limited with regard to reporting of the latter. We present a hybrid approach to repair such an aneurysm in a patient with Marfan syndrome. In a 2-stage procedure, involving initial supra-aortic bypass to all aortic arch branches, followed by endovascular stent graft deployment, the aneurysm was successfully excluded. There were no immediate complications and no evidence of endoleak at 3 months postoperatively, with thrombosis of the false lumen in the chest. By adapting hybrid open and endovascular techniques, complex thoracic aneurysms may be successfully treated in the short term in the presence of an underlying arteriopathy.

Endovascular Treatment of Carotid Stump Syndrome

Carrafiello, G., DeLodovici, M. L., Piffaretti, G., Castelli, P. — Mon, 22 Jun 2009 02:24:38 PDT

We present the case of a carotid stump syndrome in a 72-year-old woman with a 3-day history of recurrent transient ischemic attacks. Computed tomographic angiography showed the occlusion of the ipsilateral internal carotid artery, and the presence of an internal stump with ophtalmic reverse flow, confirming the suspect of a stump syndrome. The patient underwent stent-graft exclusion of the carotid stump; she was last seen 12 months after the procedure when she remained totally asymptomatic.

Endovascular Port-a-cath Insertion in a Patient With Cystic Fibrosis and Occluded Superior Vena Cava

Ali, A., Zayed, H., Wilkins, J., Wyatt, H., Rashid, H. — Mon, 22 Jun 2009 02:24:38 PDT

Introduction: Port-a-cath insertion, for long-term intravenous antibiotic therapy, is an ideal solution for patient with cystic fibrosis. However, indwelling lines are liable to many complications including catheter thrombosis especially in patients having cystic fibrosis with hypercoagulable state. Methods: An endovascular technique for insertion of a port-a-cath in a patient having cystic fibrosis with occluded superior vena cava is reported. The technique is described in detail. In addition, a review of literature for the various methods of saving a failed central venous access in these patients was performed. Results: The line was successfully inserted and remained patent without need of any further intervention for 20 months. Conclusion: In this report, several endovascular skills were used for central venous access salvage that can be used in similar situations with chronic superior vena cava occlusion, which may not be suitable for thrombolysis or stenting.

Aortic, Celiac Axis, and Superior Mesenteric Artery Thrombosis Associated With Sigmoid Colon Adenocarcinoma and Hypercoagulable State

Serck, L. C., Cogbill, T. H. — Mon, 22 Jun 2009 02:24:38 PDT

A patient with sigmoid colon adenocarcinoma and hypercoagulable state developed acute visceral ischemia secondary to thrombus involving the suprarenal aorta, celiac axis and superior mesenteric artery. A large, laminated fibrin thrombus was removed via supraceliac aortotomy. Attempts to clear thrombus from branches of the celiac axis and superior mesenteric artery by open and catheter-based techniques were of limited success. Extensive visceral infarction ensued and the patient died.

Endovascular Treatment for Traumatic Popliteal Artery Pseudoaneurysms After Knee Arthroplasty

Sloan, K., Mofidi, R., Nagy, J., Flett, M. M., Chakraverty, S. — Mon, 22 Jun 2009 02:24:38 PDT

Trauma to the popliteal artery is a recognized complication of knee arthroplasty (total knee arthroplasty). It can present in a variety of ways, one of which is the development of popliteal artery pseudoaneurysm. We report the successful endovascular management of 2 patients who developed popliteal artery pseudoaneurysms following total knee arthroplasty using covered stent grafts. From presented evidence, endovascular therapy is a safe treatment modality and it appears to be a viable alternative to open surgery.

Case Study: Chronic Femoropopliteal Prosthetic Graft Infection With Exposed Graft

McCready, R. A., Bryant, M. A., Divelbiss, J., Wack, M. F., Mattison, H. R. — Mon, 22 Jun 2009 02:24:38 PDT

One of the most feared complications following vascular reconstruction is infection due to the attendant risks of limb loss, sepsis, or death. The reported incidence of infection following infrainguinal prosthetic graft infection is 2.5% with associated mortality rates and amputation rates of 18% and 41%, respectively. There are several options in treating infected prosthetic infrainguinal bypass grafts. Some authors have advocated complete removal of the infected graft with concomitant in situ revascularization using autogenous tissue or extra-anatomic bypass using either autogenous or prosthetic material, depending upon the clinical circumstances. Other authors have advocated attempting graft preservation to decrease the risk of amputation. Infected, thrombosed grafts are generally treated with graft excision alone with care taken to preserve collateral flow. The treatment options may also be influenced by the type of infection, as infections caused by gram-negative bacteria are thought to be more virulent than those associated with gram-positive bacteria. We recently treated a patient with an 18-month history of an exposed prosthetic graft in the groin, which was infected by Proteus mirabilis. Despite the extended period of graft exposure and despite gram-negative bacteria being the causative organism, the patient reported only intermittent drainage of pus from the groin. The management of this unusual infection forms the basis of this report.

Venous Outflow Obstruction With Retroperitoneal Kaposi's Sarcoma and Treatment With Inferior Vena Cava Stenting

Mon, 22 Jun 2009 02:24:39 PDT

A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposi's sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent.

Endovascular Repair of Innominate Artery Injury Secondary to Air Rifle Pellet: A Case Report and Review of the Literature

Gifford, S. M., Deel, J. T., Dent, D. L., Seenu Reddy, V., Rasmussen, T. E. — Mon, 22 Jun 2009 02:24:39 PDT

Objective: Decreased morbidity makes endovascular treatment preferable for certain central aortic and great vessel injuries. We present a case of penetrating innominate injury, describe considerations of a catheter-based approach, and provide follow-up of repair. Methods: A case report and review of the literature. Results: A 16-year-old man presented with an isolated innominate artery injury following an air rifle wound. Standard transfemoral approach was used to gain access the innominate artery. The injury was treated with an 8 x 35 mm, balloon-expandable, covered stent. Completion imaging confirmed a well-positioned stent with exclusion of the injury and normal flow in distal vessels. There were no symptoms of stent migration or stenosis 1 year following the injury. Conclusions: Specific anatomic characteristics including its proximity to the carotid and vertebral arteries make the endovascular approach to the innominate artery unique. This case demonstrates the viability of catheter-based approaches in treating vascular injury.

Refractory In-stent Restenosis Following Carotid Artery Stenting: A Case Report and Review of Operative Management

King, B. N., Scher, L. A., Lipsitz, E. C. — Mon, 22 Jun 2009 02:24:39 PDT

In-stent restenosis following carotid artery stenting is a challenging problem that vascular surgeons will likely encounter with increasing frequency. The following describes a patient who developed progressive in-stent restenosis 3 years after carotid artery stenting, which was treated with operative therapy after failed balloon angioplasty. A review of the literature describing surgical approaches to the treatment of in-stent restenosis was also performed.

Ureteric Obstruction of Solitary Kidney Following Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm: A Case Report

Goswami, R., Rathod, K., Coker, J. — Mon, 22 Jun 2009 02:24:39 PDT

Endovascular treatment of abdominal aortic aneurysm is commonplace at present. It has got lower mortality and morbidity compared to open surgical repair. However, it requires long-term follow-up. The main complications are endoleaks, stent migrations, kinks, and rupture. Ureteric obstruction is uncommon but an important complication following endovascular treatment of abdominal aortic aneurysms. We present a case of ureteric obstruction in a solitary kidney following endovascular repair of abdominal aortic aneurysm and its successful management by ureteric stenting.

Surgical Treatment of an Extrarenal Pseudoaneurysm After Kidney Transplantation

Sharron, J. A., Esterl, R. M., Washburn, W. K., Abrahamian, G. A. — Mon, 22 Jun 2009 02:24:39 PDT

A 69-year-old man who underwent a kidney transplantation developed a large pseudoaneurysm at the anastomosis between the right external iliac artery and renal transplant artery. After an unsuccessful attempt using percutaneous thrombin injection, the patient underwent open exploratory laparotomy and surgical ligation of the pseudoaneurysm with preservation of renal graft function.

Letter to the Editor

Ysa, A., Bustabad, M., Arruabarrena, A., Perez, E. — Mon, 22 Jun 2009 02:24:39 PDT

Basic Science Review: Nitric Oxide--Releasing Prosthetic Materials

Varu, V. N., Tsihlis, N. D., Kibbe, M. R. — Tue, 21 Apr 2009 08:06:08 PDT

Prosthetic devices that come into contact with blood ultimately fail secondary to thrombus formation. This limits the utility of a variety of materials used to surgically treat cardiovascular disease, including vascular grafts and stents, as well as sensors and catheters placed within the circulatory system. Moreover, systemic anticoagulation that is used to prevent malfunction of these devices has potential for serious complications. It is known that nitric oxide (NO) produced via the endothelium imparts thromboresistant properties to native blood vessels. Thus, if NO were delivered locally to the site of the prosthetic material, it has the potential to halt thrombus formation while limiting life-threatening side effects. This review serves to examine the variety of NO-releasing materials that have been created with the two different classes of NO donors, the diazeniumdiolates and S-nitrosothiols, and the clinical applications of these prosthetics for potential future use.

The Vascular and Biochemical Effects of Cilostazol in Diabetic Patients With Peripheral Arterial Disease

Tue, 21 Apr 2009 08:06:08 PDT

Objectives: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients.

Methods: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks.

Results: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups.

Conclusions: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

Carotid Artery Angioplasty and Stenting: Introduction of a New Technique Into an Established Vascular Surgery Center

Tue, 21 Apr 2009 08:06:08 PDT

Background: The aim of this study was to review our initial experience with the introduction of carotid artery angioplasty and stenting as a treatment for carotid stenosis in high-risk patients and compare clinical outcomes to carotid endarterectomy patients treated over the same time period at our center. Methods: A total of 265 carotid revascularization procedures (45 carotid artery angioplasty and stenting and 220 carotid endarterectomy) were performed over 3 years period. In the carotid artery angioplasty and stenting group, 93% were at high risk according to the current reporting standards. Death, neurological events, and restenosis rates were compared at 30 days and at most recent follow-up. Results: Mean follow-up for all patients was 18 months (range 0-48 months). Carotid artery angioplasty and stenting group had higher cardiac risk than carotid endarterectomy group (13% vs 2%, P < .05). High-risk carotid lesions were present in 67% of carotid artery angioplasty and stenting patients. There was a tendency toward higher restenosis rate in carotid artery angioplasty and stenting than in carotid endarterectomy patients (35% vs 15%, P = .06). Combined stroke and death was higher in the carotid stenting group (4% and 9%) compared to the carotid endarterectomy group (0.5% and 0.5%) at 30 days and at late follow-up, respectively (P = .04 and .00). Conclusion: Restenosis and stroke were observed more frequently in our initial experience in patients undergoing carotid artery angioplasty and stenting compared with carotid endarterectomy patients during the same time period. These differences disappeared in high-risk patients. Further studies, to evaluate the effect of the learning curve on early results as well as follow-up for intermediate and long-term durability of carotid artery angioplasty and stenting in high-risk patients, are required.

Cerebral Hyperperfusion After Carotid Stenting: A Transcranial Doppler and SPECT Study

Tue, 21 Apr 2009 08:06:08 PDT

Aim: To document the incidence of symptomatic cerebral hyperperfusion after carotid stenting and to determine possible predisposing factors.

Methods: A prospective study of 29 consecutive patients undergoing carotid stenting. All patients underwent 1) brain computed tomography scan and magnetic resonance imaging, 2) transcranial Doppler including assessment of cerebrovascular reactivity of the ipsilateral middle cerebral artery and 3) 99m hexamethyl-propyleneamine oxime brain single photon emission computed tomography, before and after the procedure.

Results: A total of 5 patients developed adverse neurological events, 4 of them transient. Cerebral hyperperfusion was documented in two of these (6.9%). Both had exhausted cerebrovascular reactivity in the preoperative transcranial Doppler examination. No consistent pattern of interhemispheric asymmetry in brain perfusion was found in these patients.

Conclusions: Symptomatic cerebral hyperperfusion is not uncommon after carotid stenting. There seems to be a link between exhausted cerebrovascular reactivity of the ipsilateral middle cerebral artery and increased risk of cerebral hyperperfusion.

Surgical Versus Endovascular Reconstruction for Chronic Mesenteric Ischemia: A Contemporary UK Series

Tue, 21 Apr 2009 08:06:08 PDT

Objective: To assess the outcome of surgical (SR) and endovascular (ER) reconstruction for chronic mesenteric ischemia (CMI). Methods: Retrospective review of consecutive patients who underwent SR or ER for CMI in 3 UK vascular surgery units between 1996 and 2006. Early (<30 days; technical success, morbidity, mortality, length of hospital stay) and late (>30 days) outcomes (symptom recurrence, vessel/graft patency, reintervention, mortality) were assessed. Results: A total of 27 patients underwent 32 reconstructions (SR = 17, ER = 15). A total of 44 of 56 (79%) diseased arteries underwent SR (n = 26; bypass = 24, reimplantation = 2; occlusion = 16, stenosis = 10) or ER (n = 18; stenosis = 16, occlusion = 2). Perioperative mortality for SR and ER was 6% and 0%, respectively (P ≥ .99). Hospital stay was shorter following ER (mean, 4.3 vs. 14.2 days, P = .0003). Mean (range) follow-up for SR and ER was 34 (1-94) and 34 (0-135) months, respectively. At 2 years, SR demonstrated superior secondary patency (100% vs. 65%) and clinical patency (100% vs. 73%). Conclusions: Surgical mesenteric reconstruction is associated with significantly longer hospital stay, but superior long-term outcome compared to endovascular reconstruction.

Superficial Femoral Artery Autograft Reconstruction for Complicated Popliteal Artery Entrapment Syndrome

Tue, 21 Apr 2009 08:06:08 PDT

We present an alternative surgical approach to popliteal artery entrapment syndrome with vascular complications in the absence of a suitable saphenous vein. Three patients (29, 35, and 78 years old) with thrombotic and/or aneurysmal lesions of the popliteal artery from popliteal artery entrapment syndrome were treated with superficial femoral artery autograft reconstruction. The procedure was performed through a medial approach. The superficial femoral artery was harvested in the upper third of the thigh and used as the conduit for reconstruction and the harvested segment was replaced by a polytetrafluoroethylene graft. At follow-up, patients were asymptomatic and duplex ultrasound revealed patent reconstruction with no morphological abnormalities.

Ischemia-reperfusion Injury in the Lung: Quantitation Using Electron Microscopy

Tue, 21 Apr 2009 08:06:08 PDT

Background: The primary objectives of this study were to determine the time course of ischemia-reperfusion injury in an isolated rabbit lung model and to quantify this damage using electron microscopic methodology coupled with statistical analyses. Materials and Methods: Eight groups of isolated rabbit lungs (n = 5 per group) were subjected to predetermined periods of ischemia-reperfusion. Two hours of ischemia and 4 hours of reperfusion were concluded to be necessary to induce optimal ischemia-reperfusion injury in this model. Four other groups were subjected to 2 hours of ischemia followed by selected periods of reperfusion. These groups were compared to 4 control groups that were perfused for comparable time periods but without the initial ischemia. New quantitative methods were developed based on the average surface area of the alveoli and average number of alveoli per unit surface area, using scanning electron microscopic examination. Results: Ischemia per se caused substantial damage. Restoration of volume and nutrients reversed this damage at 1 hour of reperfusion, but severe damage was evident at 4 hours of reperfusion, as reported by subjective and blinded examination. By using the new quantitative methods, there was a significant difference between the groups (P < .005) according to the time of post—ischemia-reperfusion, which correlated with the subjective evaluation of damage. Conclusions: These 2 new quantitative techniques provide an objective assessment of damage in the isolated rabbit lung model, suggesting that they warrant further consideration in similar studies of ischemia reperfusion injury.

Endovenous Laser Ablation (EVLA) in Patients With Varicose Great Saphenous Vein (GSV) and Incompetent Saphenofemoral Junction (SFJ): An Ambulatory Single Center Experience

Zafarghandi, M. R., Akhlaghpour, S., Mohammadi, H., Abbasi, A. — Tue, 21 Apr 2009 08:06:08 PDT

Objectives: To evaluate treatment results for varicose great saphenous vein (GSV) using endovenous laser ablation (EVLA) in an ambulatory single center.

Material and methods: We prospectively studied 77 limbs with varicose GSV in 74 patients who were treated using 980-nm EVL with a 600-mm laser fiber and the power settings of 10-25 Watts. The patients were followed using color Doppler ultrasound.

Results: Continued closure of treated GSV was found in 98.3% of the legs evaluated at 3-week follow-up (n = 60). At 3- and 6-month intervals, 94.1% and 97% successful occlusion was achieved, respectively. The main complications of the procedure included prolonged leg pain (2 cases), hyperestheasia (one case) and lidocaine sensitivity (one case).

Conclusion: EVLA treatment of the GSV is a safe and highly effective method accompanied with few complications in midterm follow-up. It is feasible in ambulatory settings and the patients return to their daily activities early after intervention.

Self-assessment of the Training of Vascular Fellows: Survey Results of 219 Vascular Fellows From 2004 Through 2007

Tue, 21 Apr 2009 08:06:08 PDT

Introduction. In an attempt to identify the concerns of vascular fellows regarding their training in vascular surgery, we conducted a survey consisting of 22 questions at an annual national meeting from 2004 to 2007. Methods. The fellows were asked to assess various aspects of their training as excellent, satisfactory, or mixed. Results. 76% were satisfied with their endovascular experience during their fellowship while 82% were satisfied with their experience with open cases. The distribution of non-learning cases was felt to be excellent, satisfactory, or required some or much improvement in: 45%, 44%, 8%, and 2% respectively. However, only 61% felt that their vascular laboratory experience was excellent or satisfactory. Only 36% actually performed the vascular duplex exam, and only 49% felt that they would feel comfortable in managing a vascular laboratory. Conclusions. The results of this Survey suggest that several significant issues are reflected in the minds of vascular trainees.

Treatment of Dilated Venous Bypass Grafts With an Expanded Polytetrafluoroethylene-covered Nitinol Endoprosthesis

van Vugt, R., Kruse, R.R., Fritschy, W.M., Moll, F.L. — Tue, 21 Apr 2009 08:06:08 PDT

An above-knee femoropopliteal bypass graft constructed of great saphenous vein became dilated in 2 patients 12 and 25 years after surgery. Both patients had several concomitant disorders. The dilations were treated by insertion of an expanded polytetrafluoroethylene-covered nitinol endoprosthesis. There were no major procedural complications. One minor endoleak that developed immediately after endograft placement resolved within 6 weeks. The leg swelling subsided, and the endoprostheses have remained patent for 18 and 24 months, respectively. To our knowledge, these were the first cases in which an endoprosthesis was used to treat dilation of a venous bypass graft.

Unilateral Jugular Vein Phlebectasia

Gundlach, U., Unlu, C., Wust, A. F.J., Voorwinde, A. — Tue, 21 Apr 2009 08:06:08 PDT

Endovascular Management of Hoarseness Due to a Thoracic Aneurysm: Case Report and Review of the Literature

Lew, W. K., Patel, K., Haqqani, O. P., Weaver, F. A. — Tue, 21 Apr 2009 08:06:08 PDT

Although uncommon, hoarseness can be a presenting symptom of a thoracic aneurysm. We present a case of a 67-year-old man with hoarseness, subsequently found to have left vocal paralysis. On workup, a computed tomography scan demonstrated a saccular thoracic aneurysm compressing the recurrent laryngeal nerve at the aortopulmonary window. About 6 months after treatment with an endovascular stent graft, the aneurysm sac decreased in size and hoarseness resolved without further surgical intervention. Although uncommonly mentioned as an indication for surgery, hoarseness from a thoracic aneurysm can be successfully managed with endovascular stent grafting.

Novel Technique for Treatment of a Renal Artery Occlusion in a Child With Neurofibromatosis: A Combined Endovascular and Laparoscopic Approach

Lindblad, B., Lindh, M., Ivancev, K., Petersson, U., Montgomery, A. — Tue, 21 Apr 2009 08:06:08 PDT

Neurofibromatosis is associated with mid-aortic dysplasia, renal artery aneurysms and renal artery ostial stenosis, or occlusions in about 1% of cases. We describe a novel approach to recanalize an occluded renal artery in a 10-year-old girl with neurofibromatosis and difficulty in pharmacologically controlling her hypertension. Normally, when reconstruction is required, an open operative technique is used. We report on the combined use of laparoscopic exposure and percutaneous retrograde puncture of the occluded renal artery, which could be recanalized and stented. The pros and cons of this new approach are discussed.

The Nephrotic Syndrome: An Unusual Case of Multiple Embolic Events

Schwartz, J.-C. D., Wyrzykowski, A. D., Dente, C. J., Nicholas, J. M. — Tue, 21 Apr 2009 08:06:08 PDT

The nephrotic syndrome is an unusual cause of the hypercoaguable state and thromboembolic complications. Here we report the case of a 42-year-old woman with nephrotic syndrome who presented with a pulseless lower extremity and a midpole renal infarct requiring urgent embolectomy of the leg. During her embolic evaluation, she was found to have an intracardiac thrombus. Over the course of her hospitalization, she developed a pulseless upper extremity and required an embolectomy of her arm. We believe that this represents the first case report of a patient with nephrotic syndrome, intracardiac thrombus, and evidence of embolization to 3 sites: kidney, arm, and leg.

Endovascular Repair of Blunt Extremity Arterial Injury: Case Report

Zimmerman, P., d'Audiffret, A., Pillai, L. — Tue, 21 Apr 2009 08:06:08 PDT

Objective: Surgical revascularization is the standard treatment of complex blunt traumatic extremity vascular injuries. Limb salvage may be improved with minimally invasive endovascular therapies because of the ability to perform diagnostic and therapeutic intervention simultaneously. Two cases of acute limb-threatening arterial injuries successfully treated with percutaneous endovascular therapy are reported. Results: A skier suffered hemodynamic instability after shoulder reduction. An axillary arterial injury was suspected and confirmed with angiography. A covered stent successfully controlled the hemorrhage. A morbidly obese female sustained anterior dislocation of her left knee 7 years previously requiring repair. She developed recurrent knee dislocation with acute leg ischemia. Emergent fixation was performed followed by percutaneous angiography. Short segment thrombosis of the popliteal was noted. Wire recanalization of the thrombosed artery and stent placement restored 3-vessel runoff. Conclusion: Endovascular therapy can offer faster, easier access to the extremity vascular injury facilitating revascularization and avoiding long incisions and dissections.

Autogenous Arterial and Venous Reconstruction for Femoral Vein Leiomyosarcoma--A Case Report

Propper, B., Zonies, D., Smith, D., Rasmussen, T. E. — Tue, 21 Apr 2009 08:06:08 PDT

This report describes the removal of a large, symptomatic leiyomyosarcoma arising from the proximal femoral vein necessitating removal of the femoral venous and arterial circulations. Reconstruction was accomplished with autologous vein and initial coverage with ipsilateral rectus abdominus flap. Persistent, early postoperative lymphatic leak and groin sepsis secondary to staph aureus was managed with reoperation and coverage with contralateral rectus abdominus muscle flap. Negative pressure dressing device was used as a wound management adjunct and splint thickness skin graft providing final successful coverage. Two years following the operation the patient was without evidence of disease, had a patent vascular reconstruction and a well healed groin. Femoral vein leiyomyosarcoma is a rare vascular tumor, which is especially challenging to manage in the proximal location. Successful outcome is predicated on revascularization with autologous vein and on a multidisciplinary approach using various soft tissue coverage strategies and wound management adjuncts.

Book Review: Hauw T. Sie, Giuseppe D'Ancona, Fabio Bartolozzi, Willem Beukema, Donald B. Doty (editors). Surgical Treatment of Atrial Fibrillation. (256 pp)

Mahomed, Y. — Tue, 21 Apr 2009 08:06:08 PDT

Releasing Versus Ligation of 2 Tails of Large Venous Aneurysms Secondary to Dialysis Arteriovenous Fistulas

Moini, M., Rasouli, M. R., Seyedmahmoodian, H. — Tue, 21 Apr 2009 08:06:08 PDT