European Journal of Vascular & Endovascular Surgery - Articles in Press

Early Ischaemic Preconditioning of Spinal Cord Enhanced the Binding Profile of Heat Shock Protein 70 with Neurofilaments and Promoted its Nuclear Translocation after Thoraco-abdominal Aortic Occlusion in Pigs - Corrected Proof

2012-01-30

Abstract: Objective(s): Heat shock protein 70 (Hsp70) is detected in substantial amounts in normal neurons and this basal content may protect a cell against harmful conditions without the need for additional synthesis. Herein, we investigate the potential protective role of these basal levels of Hsp70, in an early ischaemic preconditioning (IPC) experimental model, suggesting a possible role of this protein as a first window of protection.Design, material and methods: Forty-two pigs were used in an experimental thoraco-abdominal aortic occlusion model. Twelve animals (two groups) were used for neurological evaluation. The remaining 30 animals (five groups) were used for immunoprecipitation and immunohistochemical studies. These were performed to study the binding relationship of Hsp70/cytoskeleton elements and the cellular distribution of Hsp70, respectively.Results: The IPC + ischaemia-group showed significant better neurologic scores compared with those of the ischaemia group, indicating a protective role for IPC (P = 0.003). The immunoprecipitations demonstrated that early IPC increased significantly the binding profile of Hsp70/neurofilaments (P = 0.025). In addition, translocation of Hsp70 into the nucleus was observed, which was conserved until the sustained ischaemia.Conclusions: These results indicate that Hsp70 may have an important role in early IPC of the spinal cord, by protecting neurofilaments and by ensuring the functionality and the integrity of the nucleus, at the time the intensive insult begins.

Young Women with PAD are at High Risk of Cardiovascular Complications - Corrected Proof

P.P. Wisman, M.J. Tangelder, E.S. van Hattum, G.J. de Borst, F.L. Moll — 2012-01-30

Abstract: Objectives: Prognostic research in patients with peripheral arterial disease (PAD) is scarce and determinants of outcome are mainly studied in males. The current management of PAD in women is based on evidence from, at best, mixed populations. We therefore assessed risk and prognostic factors in 313 men and 169 women from the Dutch Bypass Oral anticoagulants or Aspirin Study of whom long-term follow-up data were available.Method: The primary composite outcome event was vascular death, myocardial infarction, stroke, or major amputation during 5 years of follow-up. Variables with a p-value <0.2 in the univariate analyses were added to the multivariate Cox proportional hazards model.Results: Females were older (71 vs. 68 years; p < 0.01), had more advanced PAD (critical limb ischemia (CLI) 52.1 vs. 42.2%; p = 0.04), more often had peripheral bypass surgery as primary intervention (50.5 vs. 32.5%; p < 0.01), and had more often hypertension (48.5 vs. 33.2%; p < 0.01) than males. Males were more often smokers (63.6 vs. 53.3%; p = 0.03) and had more prior myocardial infarctions (18.5 vs. 10.1%; p = 0.02).In total 170 events occurred, 74 (44%) in females and 96 (31%) in males. Overall, independent risk factors for the primary outcome event were age and critical limb ischemia. Independent risk factors in males were: age (HR: 1.06, 95% CI: 1.03–1.09), critical limb ischemia (HR: 1.7, 95% CI: 1.05–2.7), and diabetes mellitus (HR: 1.7, 95% CI: 1.01–2.8) and in females critical limb ischemia (HR: 3.5, 95% CI: 2.0–6.1), ABI≤0.9 (HR: 2.8, 95% CI: 1.2–6.1), and femorocrural bypass (HR: 1.9, 95% CI: 1.1–3.3). Although sex was not an independent risk factor in the overall analysis, women younger than 60 years had an increased risk for cardiovascular events compared to men of that age (HR: 4.9, 95% CI: 1.8–13.6), whereas no difference was seen above 60 years of age.Conclusions: Risk factors for cardiovascular events in patients with PAD differ between men and women. To our knowledge, this is the first study that shows such a bad outcome in female patients younger than 60 years of age. More awareness leading to early diagnosis and optimal treatment might improve long-term clinical outcome in (young) women with PAD.

A Rare Case of Popliteal Venous Aneurysm - Corrected Proof

M. Dumantepe, I.A. Tarhan, A. Ozler, I. Yurdakul — 2012-01-30

Objective: Popliteal venous aneurysms are uncommon but potentially fatal abnormalities, since they can cause pulmonary emboli. Here, we report a case of a popliteal venous aneurysm of the right popliteal fossa.

Commentary on: Is the Incidence of Abdominal Aortic Aneurysm Declining in the 21st Century? Mortality and Hospital Admissions for England & Wales and Scotland - Corrected Proof

J.J. Earnshaw — 2012-01-30

These are fascinating data that contribute to the growing body of literature suggesting the prevalence of aortic aneurysm disease is decreasing. In the Gloucestershire Aneurysm Screening Programme which started over 20 years ago, the mean aortic diameter in 65 year old men has reduced from 21 mm to 17 mm (over 52,000 men screened). This reduction has been similar across all aortic diameters. The present authors suggest their findings may due to a reduction in smoking and an increase in aneurysm surgery in the over 75s.

The Burden of Depression in Patients with Symptomatic Varicose Veins - Corrected Proof

K. Sritharan, T.R.A. Lane, A.H. Davies — 2012-01-30

Abstract: Objective: To evaluate the burden and impact of depression in patients with symptomatic varicose veins.Methods: Patients with varicose veins referred to the vascular surgeons for further management, were invited to complete a validated questionnaire relating to quality of life, using the Aberdeen Varicose Veins Questionnaire (AVVQ), EuroQol-5D questionnaire (EQ-5D) and the EuroQol-Visual Analogue Score (EQ-VAS); and depressive symptoms, using the Centre of Epidemiological Studies Depression Scale (CES-D). Social, demographic, clinical (CEAP classification, venous clinical severity score (VCSS)) and venous disability score (VDS) data was also collected.Results: One hundred patients, mean age 52.7 years (63 females; 37 males) were recruited. Twenty-nine per cent of patients with varicose veins had depression scores suggestive of depression; no patient had previously been diagnosed or was on treatment. Depression scores were not influenced by age (p = 0.30) or gender (p = 0.60); and there was no correlation between depression scores and VCSS (p = 0.07, r2 = 0.034), or between VDS groups 1, 2 or 3 (p = 0.75). There was a weak correlation between depression scores and AVVQ (p = 0.0009, r2 = 0.12) and depression scores and EQ-5D (p < 0.0001, r2 = 0.32) and EQ-VAS (p < 0.0001, r2 = 0.25).Conclusion: Depression is prevalent in patients with symptomatic varicose veins, where it is commonly undiagnosed and untreated. A more holistic approach to patients with venous disease is therefore advocated.

Cerebral Hyperperfusion Syndrome: The Dark Side of Carotid Endarterectomy - Corrected Proof

P. De Rango — 2012-01-30

Carotid endarterectomy (CEA) is the most frequently performed surgical procedure to prevent stroke in Western countries. Nevertheless, despite the widespread use and the technical simplicity, CEA is still today a not totally known procedure and may lead to unpredictable findings such as cerebral hyperperfusion syndrome (CHS) defined as “unexpected increase in cerebral blood flow >100% potentially leading to cerebral hemorrhage”. Even if rare (nearly 10% of CEA) CHS is an upsetting complication with a catastrophic burden, especially when occurring in patients with asymptomatic carotid disease. Generally believed to be related to the lack of cerebral autoregulation in previously hypoperfused cerebral areas and favoured by high blood pressure, CHS remains largely unknown regarding causes, risk factors, clinical consequence, prevention and treatment. As of today, the only way to manage CHS is by close monitoring and aggressive use of anti-hypertensive drugs to decrease excessive cerebral perfusion.

A Spontaneous Dissecting Abdominal Aneurysm Originating from the Iliac Artery - Corrected Proof

F. Gao, J. Chen, J. Guan, Q. Zeng, F.M. Lin — 2012-01-27

Aortic dissection often involves the thoracic and abdominal aorta, whereas isolated abdominal aortic dissection is rare. Few cases of abdominal aortic dissection caused by iliac arterial dissection have been reported. Herein, we report a case of spontaneous isolated abdominal dissection in which both the entry and exit sites were in the iliac arteries. The patient was treated successfully using the endovascular aneurysm repair procedure.

A Case of Pseudo-xanthoma Elasticum Presenting with Ischaemic Claudication - Corrected Proof

C.M. Lamb, R.A. Johns, P.J. Gallagher, A. Odurny, C.P. Shearman — 2012-01-27

Abstract: A 37-year-old man presented with symptoms of intermittent claudication. Investigations revealed atypical calf vessel disease but no obvious aetiology. Ten years later he re-presented with worsening symptoms. CT angiography confirmed the atypical pattern of lower limb arterial disease but also noted calcification of the renal parenchyma, myocardium and scrotum. A diagnosis of pseudo-xanthoma elasticum was confirmed by skin biopsy. Pseudo-xanthoma elasticum is a rare condition that presents infrequently to vascular surgeons. Early recognition should prompt aggressive risk factor management to slow accelerated atherosclerosis. Clinicians should be aware of the clinical features of this condition to allow early diagnosis.

Net Effect of Lymphaticovenous Anastomosis on Volume Reduction of Peripheral Lymphoedema after Complex Decongestive Physiotherapy - Corrected Proof

J. Maegawa, M. Hosono, H. Tomoeda, A. Tosaki, S. Kobayashi, T. Iwai — 2012-01-27

Abstract: Objective: The results of reported lymphaticovenous anastomoses include some effects of complex decongestive physiotherapy (CDP). The present study aimed to determine the net effect of lymphaticovenous side-to-end anastomosis (LVSEA) in patients with lower limb lymphoedema treated by preoperative CDP.Design: Retrospective observational study.Materials: 37 LVSEAs in 31 patients.Methods: Volumes of the thigh and leg with oedema were compared between the time of initial examination, and before (application of CDP) and after LVSEA. The patients were divided into two groups based on the number of anastomoses and lymphoscintigraphic findings.Results: Preoperative CDP resulted in a reduction of 593 ml (both leg and thigh; p < 0.001). After CDP, LVSEA (1–8 anastomoses; average of 5) reduced the volume by 109 ml (52 ml for the thigh (p = 0.01) and 57 ml for the leg (p = 0.002)). There was no significant difference in volume reduction on lymphoscintigraphy. Volume was significantly reduced (by 55 ml in the thigh, p = 0.049; 96 ml in the leg, p = 0.006) in the group that underwent 6–8, but not 1–5 LVSEAs.Conclusions: The net effect of LVSEA on volume reduction was confirmed, but was not particularly large. The need for CDP decreased in some patients postoperatively, and these patients should be considered for evaluation.

Comment on ‘Stem-cell Therapy for Peripheral Arterial Occlusive Disease’ - Corrected Proof

M. Teraa, M.C. Verhaar, H. Gremmels, J.O. Fledderus, R.E.G. Schutgens, F.L. Moll — 2012-01-27

With great interest we have read the article by Kim and colleagues in this journal, demonstrating that intramuscular administration of human umbilical cord blood mononuclear cells (HCB-MNCs) enhances the number of capillaries, angiogenic gene expression and angiogenic factors in a canine hind limb ischemia model. We laud the attempt of the authors to translate their results into clinical practice, administering HCB-MNCs in patients with peripheral arterial occlusive disease (PAOD). However, this study raises some important questions.

Comments regarding “The Wonders of New Available Post-Analysis CT Software in the Hands of Vascular Surgeons” - Corrected Proof

M.T. Voûte, F.M. Bastos Gonçalves, H.J.M. Verhagen — 2012-01-27

The authors of this manuscript present a case where an endoleak was detected in a growing aneurysm sac, after endovascular aneurysm repair. This was presumed to be a type-II EL, and it was not until reconstructions with open source post-processing software were made that they discovered device failure as the origin of the endoleak.

Angiolymphoid Hyperplasia with Eosinophilia Presenting as an Ulnar Artery Pseudoaneurysm - Corrected Proof

K. Igari, T. Kudo, I. Onishi, T. Toyofuku, M. Jibiki, Y. Inoue — 2012-01-24

Introduction: Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon proliferative benign lesion, which most commonly affects the skin of the head and neck. Noncutaneous localization of this pathology is unusual, and it is rare in the extremities.

Multidisciplinary Approach to a Peripheral Arteriovenous Malformation - Corrected Proof

K. Igari, T. Kudo, T. Toyofuku, M. Jibiki, Y. Inoue — 2012-01-24

Introduction: The management of arteriovenous malformations (AVMs) remains challenging because of their unpredictable behaviour and high recurrence rate. Report: This report describes the case of a 37-year-old female with AVM in her left thigh. After twice embolotherapy, the AVM was recognised to be resectable, and intra-operative embolisation was performed to block the blood flow into the nidus of the AVM. The malformation was completely resected with minimal blood loss.

Prevention of Vascular Graft Infections with Antibiotic Graft Impregnation Prior to Implantation: In Vitro Comparison between Daptomycin, Rifampin and Nebacetin - Corrected Proof

2012-01-24

Abstract: Objective: To compare the in vitro efficacy of graft impregnation with nebacetin versus rifampin versus daptomycin against vascular graft infections caused by Staphylococcus epidermidis and Staphylococcus aureus and nebacetin versus rifampin against Pseudomonas aeruginosa and Escherichia coli.Materials: Twenty-three Dacron-grafts (1 cm2) for each micro-organism were microbiologically tested and eight grafts per antibiotic underwent viability tests against human umbilical vein endothelial cells (ECs). Fifteen grafts (5/antibiotic agent) underwent 15 min impregnation and contamination with 4 ml bacterial solution (optical density (OD600 nm): 0.20 ± 0.02). After 24-h-incubation, all grafts were washed with phosphate-buffered saline and underwent sonification to release viable adherent bacteria. OD600 nm of the solution was measured. Afterwards, six 1:10 dilution steps took place and colony-forming units (CFUs) were counted.Results: Nebacetin showed comparable efficacy to daptomycin against Gram-positive bacteria. Both eradicated more efficiently S. epidermidis than rifampin (daptomycin:0, rifampin:5 ± 7.3, nebacetin:0 CFU ml−1, P = 0.0003). All antibiotics showed comparable antibacterial activity against S. aureus. Nebacetin was more efficient than rifampin to eradicate Gram-negative organisms (P. aeruginosa: rifampin:1308 ± 252, nebacetin:8 ± 8 CFU ml−1, P = 0.01, E. coli: rifampin:294 ± 159, nebacetin:0.2 ± 0.5 CFU ml−1, P = 0.001), while only rifampin was toxic against ECs (daptomycin:30.88 ± 5.44, rifampin:5.13 ± 5.08, nebacetin:28.50 ± 3.82 ECs/field, P = 0.0003).Conclusions: Nebacetin showed excellent in vitro antibacterial activity against both Gram-positive and -negative pathogens representing an effective candidate for vascular graft impregnation.

Indocyanine Green Angiography for Intra-operative Assessment in Vascular Surgery - Corrected Proof

2012-01-24

Abstract: Objectives: Indocyanine green (ICG) angiography is used for the intra-operative assessment of the graft vessel in coronary artery bypass grafting to enable immediate revision if necessary. We report the feasibility and implications of an ICG colour imaging system, HyperEye Medical System (HEMS), in surgeries for arteriosclerosis obliterans (ASO) and abdominal aortic aneurysm (AAA) which carry risk of mesenteric ischaemia.Methods: HEMS ICG angiography was used for the intra-operative assessment of 12 ASO patients and 10 AAA patients.Results: In the ASO patients, HEMS angiography enabled visualisation of the graft and native artery. The fluorescent lucent region in the artery distal to the anastomosis was shown in 1 of 12 ASO patients. There was a 3-s time lag in the increase of intensity between the proximal artery and distal stenotic region. In AAA patients, HEMS angiography clearly showed the perfusion in the mesenteric arteries and intestinal wall as opaque. One AAA patient had segmental ischaemia due to thromboembolism and another one had diffuse ischaemia due to systemic malperfusion. The ischaemic region of the intestine was visualised as a fluorescent lucent area by HEMS angiography.Conclusion: HEMS angiography can accurately assess peripheral arterial perfusion in surgical cases with ASO and AAA.

Risk of Radiation Exposure during Endovascular Aortic Repair - Corrected Proof

P. Howells, R. Eaton, A.S. Patel, P. Taylor, B. Modarai — 2012-01-24

Abstract: Objective: Exposure to radiation doses above 2 Gray (Gy) can cause skin burns. There is also a lifetime cancer risk of ≈5.5% for every Sievert (Sv) of radiation. We assessed the radiation burden associated with endovascular treatment of the aorta.Method: Thoracic (TEVAR), Infra-renal (IEVAR) and branched/fenestrated (BEVAR/FEVAR) endovascular aortic repairs were studied. The prospectively recorded dosimetric parameters included: fluoroscopy time and dose area product (DAP). Exposure films, placed underneath 10 patients intra-operatively, recorded skin dose and were used to calculate skin (Gy) and tissue (Sv) doses.Results: The TEVAR cohort (n = 232) were younger (p < 0.0001) than BEVAR/FEVAR (n = 53) and IEVAR (n = 630). The median DAP was higher (p = 0.004) in the BEVAR/FEVAR group compared with IEVAR and TEVAR: 32,060 cGy cm2 (17,207–213,322) vs 17,300 cGy cm2 (10,940–33,4340) vs 19,440 cGy cm2 (11,284–35,101), respectively. The equivalent skin doses were BEVAR/FEVAR: 1.3 Gy (0.71–8.75); IEVR: 0.71 Gy (0.44–13.7); TEVAR: 0.8 Gy (0.46–1.44). The whole body effective doses were BEVAR/FEVAR: 0.096 Sv (0.052–0.64); IEVR: 0.053 Sv (0.033–1.00); TEVAR: 0.058 Sv (0.034–0.11).Conclusions: The radiation exposure during endovascular aortic surgery is relatively low for the majority but some patients are exposed to very high doses. Efforts to minimise intra-operative exposure and graft surveillance methods that do not use radiation may reduce the cumulative lifetime malignancy risk.

Endurance Athletes with Intermittent Claudication Caused by Iliac Artery Stenosis Treated by Endarterectomy with Vein Patch – Short- and Mid-term Results - Corrected Proof

M.H.M. Bender, G. Schep, S.W. Bouts, F.J.G. Backx, F.L. Moll — 2012-01-24

Abstract: Introduction: Endurance athletes may suffer from intermittent claudication. A subgroup of 16% has severe iliac artery stenosis due to endofibrosis. In this study we report the short- and mid-term results of endarterectomy with venous patching.Patients/methods: Athletes with claudication-like complaints were analysed using a protocol including cycling test and provocative echo-Doppler. Thirty-six athletes were diagnosed with serious iliac flow limitation (one bilateral), confirmed by additional magnetic resonance (MR) angiography. Endarterectomy with venous patching was performed for 32 iliac artery stenosis and five occlusions. Postoperative (mean 15.6 months) 33 legs were evaluated using the same diagnostic protocol. A complete follow-up after mean 29 months was obtained by questionnaire.Results: Twenty-eight athletes were symptom free or could perform on a desired level with minor remaining complaints. Two athletes were satisfied though minor complaints prohibited high competition performance. Two athletes developed a re-stenosis and became symptom free after an additional operation. Three athletes had objective improvement but limited decrease in symptoms. One was unsatisfied but refused postoperative tests. The only major surgical complication was a postoperative bleeding necessitating re-operation. Postoperative tests showed significant increase in maximal workload and post-exercise ankle–brachial index. No aneurysm formation was detected.Conclusions: Precise diagnosis and meticulously performed endarterectomy with vein patching have satisfactory results in mid-term follow-up with acceptable risk in endurance athletes complaining of intermittent claudication due to iliac artery stenosis.

Superficial Vein Thrombosis in Patients with Varicose Veins: Role of Thrombophilia Factors, Age and Body Mass - Corrected Proof

2012-01-20

Abstract: Objectives: To investigate the association of various risk factors including thrombophilia defects, in patients with varicose veins (VVs) and history of episodes of superficial vein thrombosis (SVT).Materials and methods: Two hundred and thirty patients with primary VVs were included in this prospective study. A total of 128 (43 men, age 56 ± 13) had an acute episode or a previous history of SVT, while 102 patients (27 men, age 48 ± 12) did not. Coagulation profile investigation included serum levels of protein C (PC), protein S (PS), anti-thrombin III (AT III), plasminogen (Plg), A2 antiplasmin (A2Apl) and activated protein C resistance (APCR). This was performed at least 3 months after the SVT episode to ensure that the results were not altered. Age and body mass index (BMI) were also assessed.Results: PC deficiency was detected in 3/128 (2.3%), PS deficiency in 19/128 (14.8%), AT III deficiency in 29/128 (22.7%), Plg deficiency in 9/128 (7%), A2Apl excess in 3/128 (2.3%) and APCR in 9/128 (7%) patients with SVT and 0/102 (0%), 3/102 (2.9%), 15/102 (14.7%), 6/102 (5.8%), 0/102 (0%) and 1/102 (0.9%) in the control group, respectively. BMI greater than 30 kg m−2 was associated with SVT. In logistic regression analysis SVT was associated with PS deficiency (odds ratio (OR) 6.7, p = 0.004, 95% confidence interval (CI) 1.83–24.53), obesity (OR 3.5, p = 0.003, 95% CI 1.53–8.05) and age (OR 1.038, p = 0.001, 95% CI 1.01–1.06).Conclusions: Obesity, age and PS deficiency were found as factors associated with SVT episodes in patients with VVs.

Gender Disparities in Disease-specific Health Status in Postoperative Patients with Peripheral Arterial Disease - Corrected Proof

2012-01-20

Abstract: Objectives: To investigate gender disparities in disease-specific health status (HS), 3- and 5-year post-intervention in peripheral arterial disease (PAD) patients.Design: Cohort study.Methods: Data of 711 consecutively enrolled vascular surgery patients were collected in 11 hospitals in The Netherlands in 2004. HS was assessed with the Peripheral Artery Questionnaire (PAQ). Our sample included patients for whom it was possible to calculate a PAQ summary score at 3- and 5-year follow-up (n = 351).Results: Women experienced worse physical health (52.1 vs. 62.0, P = 0.012), greater disability (64.5 vs. 71.1, P = 0.026), and worse overall HS (58.1 vs. 66.7, P = 0.007) at 3-year follow-up than men. At 5-year follow-up, however, male and female patients reported similar levels of HS. Mean changes in overall HS from 3- to 5-year follow-up were significantly different for men and women (−4.12 vs. 1.69, P = 0.014). In male patients, overall HS was significantly lower at 5-year follow-up compared to the 3-year follow-up (66.7 vs. 62.6, P = 0.001). In female patients, there was no significant difference (58.1 vs. 59.8, P = 0.393).Conclusions: Men and women experience different levels of HS over time. Attention should be paid to gender disparities in postoperative PAD patients.

Prediction of Cerebral Hyperperfusion after Carotid Endarterectomy with Transcranial Doppler - Corrected Proof

2012-01-20

Abstract: Objectives: To determine the diagnostic value for predicting cerebral hyperperfusion syndrome (CHS) by adding a transcranial Doppler (TCD) measurement in the early postoperative phase after carotid endarterectomy (CEA).Design: Patients who underwent carotid endarterectomy between January 2004 and August 2010 and in whom both intra- and postoperative TCD monitoring were performed were included.Methods: In 184 CEA patients the mean velocity (Vmean) preoperatively (V1), pre-clamping (V2), post-declamping (V3) and postoperatively (V4) was measured using TCD. The intra-operative Vmean increase ((V3 − V2)/V2) was compared to the postoperative increase ((V4 − V1)/V1) in relation to CHS. CHS was diagnosed if the patient developed neurological complaints in the presence of a preoperative Vmean increase >100%.Results: Sixteen patients (9%) had an intra-operative Vmean increase >100% and 22 patients (12%) a postoperative Vmean increase of >100%. In 10 patients (5%) CHS was diagnosed; two of those had an intra-operative Vmean increase of >100% and nine postoperative Vmean increase >100%. This results in a positive predictive value of 13% for the intra-operative and 41% for the postoperative measurement.Conclusions: Besides the commonly used intra-operative TCD monitoring additional TCD measurement in the early postoperative phase is useful to more accurately predict CHS after CEA.

The Basilic Vein: An Alternative Conduit for Complex Iliofemoral Reconstruction - Corrected Proof

T. Spahos, F. Torella — 2012-01-20

Abstract: Objectives: To evaluate the basilic vein as an alternative conduit in iliofemoral arterial reconstructions.Design: Retrospective cohort study.Methods: We reviewed records of all patients undergoing iliofemoral arterial reconstruction with basilic vein between January 2006 and November 2011. Patients were identified via a prospective database, which also provided data on patients’ comorbidity, indications for surgery and perioperative outcome. Long term outcome was confirmed by reviewing hospital records; graft patency was confirmed by clinical examination and imaging by ultrasound or CT angiography.Results: We identified 15 patients undergoing 17 procedures (two patients underwent staged bilateral iliofemoral bypasses). Indications for vein (instead of prosthetic) graft use included prosthetic infection (4), suspected infection (2), proven hypercoagulable state (3), young age (3) and multiple graft occlusions (5). Preoperative mapping confirmed vein suitability in all cases, and all conduits were harvested from the upper limb. There were no major perioperative complications. After a median (range) follow up of 21.5 (1–42) months, all grafts were patent; one patient required secondary intervention on the graft.Conclusion: Iliofemoral arterial reconstruction with autologous basilic vein is feasible and may be a valid alternative when the use of prosthetic material is contraindicated.

High-dose Preoperative Fractionated Radiotherapy Does not Affect the Patency and Healing of ePTFE Vascular Prosthesis after Replacement of Canine Abdominal Aorta and Inferior Vena Cava - Corrected Proof

Y. Guo, C. Shu, X. Zhou, X. Jiang, Q. Li — 2012-01-19

Abstract: Background: Fractionated radiotherapy allows for the safe administration of larger doses without the development of immediate or late toxicity. The influence of preoperative fractionated radiotherapy on neointima formation for expanded polytetrafluoroethylene (ePTFE) graft has not been determined.Methods: Twenty mongrel dogs were randomly divided into radiotherapy group (a total dose of 35 Gy) or control group (no radiation). The infrarenal abdominal aorta and inferior vena cava were replaced by ePTFE grafts at 3 months after irradiation in the radiotherapy group. Grafts were explanted at 4 weeks after surgery. Histopathological techniques were undertaken to evaluate graft neointima formation. The control group was managed the same as the radiotherapy group except for not receiving irradiation.Results: Four grafts implanted into inferior vena cava in the irradiated group and three in the control group were found to be completely occluded. None of the grafts implanted into abdominal aorta were obstructed. In the case of the inferior vena cava graft, the thickness of the graft neointima did not differ significantly between the irradiated and control groups. However, for the abdominal aorta graft, the neointima thickness in the irradiated groups was significantly thinner than that in the control group.Conclusion: Preoperative fractionated radiotherapy affects vascular healing via suppressing the development of neointima formation in the abdominal aorta graft.

Mid-term Outcomes following Emergency Endovascular Aortic Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms - Corrected Proof

A. Noorani, A. Page, S.R. Walsh, K. Varty, P.D. Hayes, J.R. Boyle — 2012-01-19

Abstract: Objective: Emergency Endovascular Aortic Aneurysm Repair (eEVAR) is a rapidly evolving approach to ruptured Abdominal Aortic Aneurysms (rAAA). Yet longer-term outcomes following eEVAR remain unclear. This study compares mid-term outcomes of eEVAR and open rAAA.Methods: A prospective database for all patients undergoing eEVAR and open rAAA from January 2006 to April 2010 was analysed. Patients were offered eEVAR if anatomically suitable.Results: 52 patients (45 male, median age 78 years (62–92 years), underwent eEVAR, 50 patients (44 male, median age = 71 (62–95 years) underwent open rAAA repair. In-hospital mortalities were 12% (6/52) for eEVAR, 32% (16/50) for open repair.There were five re-interventions (10%) in the eEVAR group. The peri-operative survival benefits of eEVAR over open rAAA repair were maintained at 1 and 2 years post-operatively with open repair demonstrating a two-fold increased risk of mortality (Hazard ratio 2.2, Fisher Exact test, 95% Confidence Interval (CI) 1.108–4.62, p = 0.0122). Overall survival was 81% at 1 year, 73% at 2 years for eEVAR, and 62% at 1 year and 52% at 2 years for open rAAA repair.Conclusion: EEVAR is associated with excellent mid-term survival in this cohort. We would recommend eEVAR as the management of choice for rAAA in anatomically suitable patients where local facilities and expertise exist.

Unselected Percutaneous Access with Large Vessel Closure for Endovascular Aortic Surgery: Experience and Predictors of Technical Success - Corrected Proof

2012-01-19

Abstract: Introduction: The effectiveness of percutaneous access with large vessel closure (pEVR) in non-selective groups of patients undergoing endovascular aneurysm repair (EVR) remains unclear. This study aims to identify factors that predict success in pEVR, performed using percutaneous access and the Prostar XL (Abbott Vascular, Redwood City, Calif) closure device.Method: Consecutive patients who underwent pEVR between April 2010 and March 2011 were identified from a prospectively maintained database. Procedural and postoperative outcomes were compared with consecutive patients who underwent endovascular aneurysm repair using standard open femoral access between April 2008 and March 2009. To determine the predictors of technical success of pEVR, the association between clinical, anatomical and procedural variables with technical success, were examined in a multiple logistic regression model.Results: pEVR was attempted in 186 common femoral arteries (CFAs) with a technical success rate of 95.2% (177/186). Conventional open femoral access in the historic control group was performed in 208 CFAs. pEVR was associated with a reduced operation length (131 min [105–152] versus 150 min [124–195], p≤0.001) and length of stay (2 days [2–5] versus 4 days [2–7], p = 0.01) in patients undergoing infrarenal EVR.In secondary analysis of outcomes following percutaneous access in 91 CFAs, pre-operative renal failure, CFA depth (min and max), CFA diameter (min and max) and operator experience predicted success of percutaneous access in univariate analysis. Operator experience was the only independent predictor of technical success (p = 0.05) after adjustment for all confounding variables.Conclusion: pEVR using the Prostar XL device is effective in the majority of patients. In this study there were benefits in terms of reduced postoperative complications, shorter procedures and decreased lengths of stay. Operator experience is a predictor of technical success for pEVR, irrespective of clinical and morphological characteristics at baseline.

Age- and Gender-related Differences in the Use of Secondary Medical Prevention after Primary Vascular Surgery: A Nationwide Follow-up Study - Corrected Proof

A. Høgh, J.S. Lindholt, H. Nielsen, L.P. Jensen, S.P. Johnsen — 2012-01-16

Abstract: Objective: This study examined the possible age- and gender-related differences in the use of secondary medical prevention following primary vascular reconstruction in a population-based long-term follow-up study.Methods: Using information from nationwide Danish registers, we identified all patients undergoing primary vascular reconstruction in-between 1996 and 2006 (n = 20,761). Data were obtained on all filled prescriptions 6 months and 3, 5 and 10 years after primary vascular reconstruction. Comparisons were made across age and gender groups, using men 40–60 years old as a reference.Results: Compared to current guidelines the overall use of secondary medical prevention was moderate to low (e.g., lipid-lowering drugs 49.5%, angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists (ACE/ATII) 43.4%, combination of lipid-lowering drugs and anti-platelet therapy and any anti-hypertensive therapy 44.7%). A decline was observed between 6 months and 3 years after surgery. Patients >80 years old were less likely to be prescribed lipid-lowering drugs and combination therapy (e.g.: adjusted risk ratio (RR) 5 years after surgery for men and women 0.63 (95% confidence interval (CI): 0.39–1.02) and 0.48 (95%CI: 0.31–0.75), respectively, whereas smaller and statistical non-significant gender-related differences were observed. The age- and gender-related differences appeared eliminated or substantially reduced in the latest part of the study period (2001–2007).Conclusion: We found moderate to low use of secondary medical prevention in Denmark compared with recommendations from clinical guidelines. However, the use has increased in recent years and age- and gender-related differences have been reduced or even eliminated.

Carotidynia: A Rare Diagnosis in Vascular Surgery Practice - Corrected Proof

K.E.A. van der Bogt, W.M. Palm, J.F. Hamming — 2012-01-13

Carotidynia is a rare diagnosis for unilateral neck pain without a clear physical substrate. As such, it may be encountered in surgery practice when analysing carotid artery status in symptomatic patients. Here, a case is presented which outlines the diagnostic process and subsequent treatment of carotidynia. As opposed to vascular causes of unilateral neck pain, carotidynia can be easily treated conservatively. Relief of complaints as well as regression of perivascular inflammation on magnetic resonance imaging can be effectively achieved with the use of non-steroidal anti-inflammatory drugs.

Response to “Comment on ‘Insulin-like Growth Factor 1 – A Novel Biomarker of Abdominal Aortic Aneurysm’” - Corrected Proof

J.S. Lindholt — 2012-01-13

Mr. Koole and his prominent co-authors are thanked for their interest in our work and the kind words. This Viborg cohorte has demonstrated many significant and unsignificant associations, so the risk of some chance findings is obvious. Mr. Koole et al. propose to add diabetes mellitus and use of glucocorticoids in the adjusting multivariate analysis. However, use of glucocorticoids is already included, and there were not many with diagnosed diabetics (N = 7). Consequently, IgF remained unchanged and significantly associated with growth rate. We have no variables concerning physical stress, and we did not measure HbA1c or hsCRP.

Surveillance Imaging Modality does not Affect Detection Rate of Asymptomatic Secondary Interventions following EVAR - Corrected Proof

E. Chisci, F. Setacci, F. Iacoponi, G. de Donato, A. Cappelli, C. Setacci — 2012-01-12

Abstract: Objectives: Literature reports that surveillance imaging following endovascular aortic aneurysm repair (EVAR) gives rise to asymptomatic secondary interventions (SI) in 1.4–9% of cases. This retrospective study aimed to evaluate whether the modality of surveillance imaging influences the detection rate of asymptomatic SI.Materials and methods: Two EVAR surveillance protocols were compared at the same vascular centre. Protocol I, performed from January 2003 to December 2006, consisted of colour duplex ultrasound scan (CDU) plus CT angiography (CTA) 1 month after procedure and every 6 months thereafter. Protocol II, performed from January 2007 to June 2010, consisted of CDU plus CTA 1 month after operation and CDU plus plain abdominal films (XR) every 6 months thereafter. In the second protocol, CTA was carried out only during follow-up in specific conditions. The term ‘asymptomatic SI’ was used when the necessity for SI was detected by imaging alone on an elective basis, prior to development of any symptoms.Results: Enrolment included 376 and 341 consecutive patients with a mean follow-up of 1148 days (range 1–3204 days) and 942 days (range1–1512 days) in Protocols I and II, respectively (p < 0.001). Freedom rates from aneurysmal rupture, freedom from SI and detection rate for asymptomatic SI at 3 years were 98.3% and 98.7% (p = 0.456), 82% and 83.5%(p = 0.876) and 8.8% (n = 33/376) and 8.5%(n = 25/341) (p = 0.49) in Protocols I and II, respectively. Estimated comparison of the costs, radiation exposure and contrast used at 3 years in Protocol I versus Protocol II showed that Protocol II allowed for a three-, four- and six fold reduction in overall costs, radiation exposure and contrast used, respectively (p < 0.0001).Conclusions: The detection rate of asymptomatic SI following EVAR is not affected by the type of surveillance imaging. A surveillance schedule based primarily on CDU and XR appears to be justified.

Midterm Outcomes and Risk Stratification after Endovascular Therapy for Patients with Critical Limb Ischaemia due to Isolated Below-the-knee Lesions - Corrected Proof

2012-01-12

Abstract: Objectives: To assess and risk stratify midterm clinical outcomes after endovascular therapy (EVT) by angioplasty only of patients with critical limb ischaemia (CLI) due to isolated below-the-knee (BTK) lesions.Design: Retrospective multicenter study.Materials and methods: Between March 2004 and October 2010, 465 limbs (Rutherford 5 and 6: 79%) from 406 patients were studied. Overall survival, limb salvage, and re-intervention were examined out to 3 years by the Kaplan–Meier method and the log-rank test. Their independent predictors and risk stratification were analysed.Results: Patient age was 71 ± 11 yrs, with 69% diabetics and 60% on dialysis. Mean follow-up was 18 ± 15 months. Overall survival was 76 ± 2 and 57 ± 4% at 1 and 3, years, respectively. Survival predictors were body mass index <18, non-ambulatory status and ejection fraction <45%. Two-year limb salvage rate was 80 ± 2%. Factors associated with major amputation were ulcers (Rutherford 6), diabetes mellitus, C-reactive protein>5 mg/dL, and age < 60 years. Two-year freedom from re-intervention was 66 ± 3%; age and below-the-ankle runoff number after angioplasty was negatively associated with re-intervention.Conclusions: Despite relatively high mortality and re-intervention rates, limb salvage rate was acceptable after EVT for CLI patients with isolated BTK lesions. Risk stratification allows occurrence estimation for each end point.

The Use of Transcutaneous Oximetry to Predict Healing Complications of Lower Limb Amputations: A Systematic Review and Meta-analysis - Corrected Proof

2012-01-12

Abstract: Objective: To determine the validity of transcutaneous oximetry (TcPO2) as a predictor of lower limb amputation healing complications.Design: A systematic review and meta-analysis.Methods: We searched five major medical databases, relevant review articles and reference lists and included all studies that evaluated TcPO2 for its ability to predict lower limb amputation healing failure. We selected eligible articles and conducted data abstraction independently and in duplicate.Results: Thirty-one studies, enrolling 1824 patients with 1960 amputations, met our inclusion criteria. Only one study reported undertaking a multivariable analysis, which demonstrated that a TcPO2 level below 20 mmHg was an independent predictor of re-amputation occurrence (adjusted odds ratio (OR) 3.08, 95% confidence interval (CI) 1.19–7.98). Fourteen prospective cohort studies reported data that allowed for the calculation of an unadjusted relative risk of lower limb amputation healing complications leading to amputation revision associated with a TcPO2 level below cut-offs of 10 mmHg (1.80; 95% CI 1.19–2.72), 20 mmHg (1.75; 95% CI 1.27–2.40) 30 mmHg (1.41; 95% CI 1.22–1.62) and 40 mmHg (1.24; 95% CI 1.13–1.39).Conclusions: This review suggests that TcPO2 predicts healing complications of lower limb amputations. A value of less than 40 mmHg results in a 24% increased risk of healing complication compared to over 40 mmHg and the risk further increases as the TcPO2 decreases. There is, however, insufficient evidence to judge whether this tool adds important information beyond clinical data or to suggest an optimal threshold value. There is a need for a large, sufficiently powered study that adjusts for appropriate clinical variables.

Analysis of Stroke after TEVAR Involving the Aortic Arch - Corrected Proof

G. Melissano, Y. Tshomba, L. Bertoglio, E. Rinaldi, R. Chiesa — 2012-01-12

Abstract: Objective: To analyse the incidence of stroke after thoracic endovascular aortic repair (TEVAR) for aortic arch disease.Methods: In the last decade, 393 patients received TEVAR at our Institution; in 143 cases the aortic arch was involved (32 zones ‘0’, 35 zones ‘1’ and 76 zone ‘2’). The left subclavian artery (LSA) was revascularised selectively in 75 cases; the proximal LSA was ligated or occluded with a plug in 55 cases before endograft (EG) deployment.Results: Initial clinical success, perioperative mortality, spinal cord ischaemia and stroke in TEVAR patients with or without arch involvement were, respectively, 86.7% vs. 94.4%, 4.2% vs. 2.4%, 2.1% vs. 3.6% and 2.8% vs. 1.2%. The stroke rate was 9.4% (P < 0.02) in ‘zone 0’, 0% in ‘zone 1’ and 1.3% in ‘zone 2’ with scans showing severe atheroma and/or thrombus in all cases. Stroke was observed in patients with 2.6% or without 2.9% LSA revascularisation; however, it was never observed in patients in whom the LSA was occluded before EG deployment and in 4.5% of patients in whom it was patent at the time of EG deployment.Conclusions: Stroke after TEVAR is not infrequent especially when the arch is involved. Careful patient selection together with a strategy to reduce embolisation such as occlusion of supra-aortic trunks before EG deployment may play a beneficial role.

Long-term Results of Iliac Aneurysm Repair with Iliac Branched Endograft: A 5-Year Experience on 100 Consecutive Cases☆ - Corrected Proof

2012-01-12

Abstract: Background: Iliac branch device (IBD) technique has been introduced as an appealing and effective solution to avoid complications occurring during repair of aorto-iliac aneurysm with extensive iliac involvement. Nevertheless, no large series with long-term follow-up of IBD are available. The aim of this study was to analyse safety and long-term efficacy of IBD in a consecutive series of patients.Methods: Between 2006 and 2011, 100 consecutive patients were enrolled in a prospective database on IBD. Indications included unilateral or bilateral common iliac artery aneurysms combined or not with abdominal aneurysms. Patients were routinely followed up with computed tomography. Data were reported according to the Kaplan–Meier method.Results: There were 96 males, mean age 74.1 years. Preoperative median common iliac aneurysm diameter was 40 mm (interquartile range (IQR): 35–44 mm). Sixty-seven patients had abdominal aortic aneurysm >35 mm (IQR: 40–57 mm) associated with iliac aneurysm. Eleven patients presented hypogastric aneurysm. Twelve patients underwent isolated iliac repair with IBD and 88 patients received associated endovascular aortic repair. Periprocedural technical success rate was 95%, with no mortality. Two patients experienced external iliac occlusion in the first month. At a median follow-up of 21 months (range 1–60) aneurysm growth >3 mm was detected in four iliac (4%) arteries. Iliac endoleak (one type III and two distal type I) developed in three patients and buttock claudication in four patients. Estimated patency rate of internal iliac branch was 91.4% at 1 and 5 years. Freedom from any reintervention rate was 90% at 1 year and 81.4% at 5 years. No late ruptures occurred.Conclusions: Long-term results show that IBD use can ensure persistent iliac aneurysm exclusion at 5 years, with low risk of reintervention. This technique can be considered as a first endovascular option in patients with extensive iliac aneurysm disease and favourable anatomy.

When is Supervised Exercise Therapy Considered Useful in Peripheral Arterial Occlusive Disease? A Nationwide Survey among Vascular Surgeons - Corrected Proof

2012-01-12

Abstract: Objectives: Although international guidelines state that supervised exercise therapy (SET) should be offered to all patients with intermittent claudication (IC), SET appears to be underutilised in clinical practice. The aim of this study was to document current opinions of Dutch vascular surgeons on SET as treatment option for peripheral arterial occlusive disease (PAOD).Materials and methods: Vascular surgeons and fellows in vascular surgery were asked to complete a 24-question survey either at the 2011 Annual Meeting of the Dutch Society for Vascular Surgery or online.Results: Ninety-one participants, including 83 vascular surgeons (51% of all Dutch vascular surgeons), completed the survey. The respondents would refer 75.4% of newly diagnosed patients with IC for SET. SET was considered less useful in patients with IC and major (cardiopulmonary) co-morbidity or a significant iliac artery stenosis. In critical limb ischaemia, the combination of SET and angioplasty was considered useful in 71.9%. Respondents regarded patient satisfaction (63.3%) and improvement in pain-free or maximal walking ability (26.6%) as clinically most relevant goals of SET. Most (84.4%) agreed that SET should also include lifestyle management.Conclusion: Although the vast majority of Dutch vascular surgeons consider SET as an important treatment option for PAOD, SET should receive more emphasis in clinical practice since arguments not to refer for SET are outdated. Furthermore, vascular surgeons agree that lifestyle management should be integrated in SET.

Carotid Revascularization to Prevent Stroke - Corrected Proof

G.J. de Borst, L.J. Kappelle, F.L. Moll — 2012-01-12

Trial after trial, carotid angioplasty with stenting (CAS) has shown inferior results compared to carotid endarterectomy (CEA) in terms of prevention of stroke and stroke-related death. The International Carotid Stenting Study (ICSS), still the largest randomized trial in recently symptomatic patients, reported a significantly lower peri-procedural risk for patients undergoing CEA than for patients randomized to CAS (30 day rate of death/stroke 7.4% after CAS vs 3.4% after CEA (per protocol analysis HR 2.16 (95% CI 1.4–3.3)). At first glance, the main conclusions from the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), which included both symptomatic and asymptomatic patients, did suggest equivalence of CAS and CEA, with no significant difference between CAS and CEA in the rates of the primary composite endpoint 30 day risk of death/stroke/myocardial infarction (MI), or any ipsilateral stroke within four years (7.2% and 6.8%, respectively (HR with CAS 1.11; 95% CI 0.81 to 1.51; p = 0.51). However, CREST also showed a significantly higher peri-operative stroke rate for CAS 4.1% vs. 2.3% after CEA (HR 1.79 (95% CI 1.14–2.82)). The similar benefit between both procedures for the primary endpoint, was mainly driven by the intensively discussed and criticized inclusion of “silent” or “biochemical” MI in the composite endpoint. Based on the primary endpoint, CREST results were wrongly interpreted even in well respected media, stating that “CAS and CEA were equally as safe and effective in terms of stroke prevention”. In reality, ICSS and CREST actually showed very similar results, namely twice as many strokes associated with stenting as with endarterectomy. Furthermore, a pooled analysis of EVA-3S, SPACE, and ICSS showed substantially more peri-procedural deaths (RR 1.96 CI 1.04–3.72), and more peri-procedural stroke and death (RR 1.78 CI 1.40–2.25) with CAS than with CEA. Interestingly, this meta-analysis observed heterogeneity between different age groups, with a significant difference recorded only between CAS and CEA in patients older than 70 years (12.0% vs. 5.9%, risk ratio 2.04, 95% CI 1.48–2.82). In patients younger than 70 years, no difference was noted between CAS and CEA, but the 95% confidence interval (0.68–1.47) did not exclude a difference in either direction. So, for symptomatic patients with carotid stenosis >50% CAS is factually less safe and effective in terms of stroke prevention, particularly for patients older than 70 years.

Comment on ‘Insulin-like Growth Factor 1 – A Novel Biomarker of Abdominal Aortic Aneurysm’ - Corrected Proof

D. Koole, J.A. van Herwaarden, G. Pasterkamp, F.L. Moll — 2012-01-12

With great interest we read the article, insulin-like growth factor 1 – A novel biomarker of abdominal aortic aneurysm by Lindholt et al. Biomarker research for abdominal aortic aneurysm (AAA) development, progression, and rupture has attracted a lot of interest. Although this field holds promise, biomarker studies are complex and challenging in AAA disease. Lindholt and colleagues have revealed many interesting biomarkers, and therefore the authors are applauded.

Validation of a New Duplex Derived Haemodynamic Effectiveness Score, the Saphenous Treatment Score, in Quantifying Varicose Vein Treatments - Corrected Proof

C.R. Lattimer, E. Kalodiki, M. Azzam, G. Geroulakos — 2012-01-12

Abstract: Objectives: To evaluate a duplex-derived score for varicose vein treatments using numerical values of haemodynamic effectiveness.Design: The saphenous treatment score (STS) was developed prospectively to compare the effect of endovenous treatments on reflux within saphenous segments.Patients: Sixty-six patients were randomised to endovenous laser ablation (EVLA) or ultrasound-guided foam sclerotherapy (UGFS) to the great saphenous vein (GSV).Methods: Assessments included the Aberdeen varicose vein severity score (AVVSS), the venous clinical severity score (VCSS), the venous filling index (VFI) and the STS.Results: A mean STS of 5.70 decreased to 3.30, P < .0005, post-treatment. The median (IQR) AVVSS, VCSS and VFI (ml/sec) decreased from 21.52(15.48) to 18.86(11.27), P = .14, from 6(4) to 3(4), P < .0005 and from 7.1(6.9) to 1.9(.9) P < .0005, respectively. In 15 patients requiring additional UGFS the mean STS values decreased from 5.8 to 4.13 and then to 2.6 P < .0005, respectively. The individual above and below knee mean treatment differences in STS on 38 EVLA and 28 UGFS patients were 1.92 and .87 (EVLA) compared to 1.57and .29 (UGFS) P = .001, respectively.Conclusions: The STS has been shown to grade the haemodynamic effects of different treatments as well as ongoing treatments on the GSV.

Catheter-based Radiofrequency Renal-nerve Ablation in Patients with Resistant Hypertension - Corrected Proof

M. Azizi, O. Steichen, M. Frank, G. Bobrie, P.-F. Plouin, M. Sapoval — 2012-01-11

Abstract: This review aims to describe the role and the results of catheter-based renal nerve ablation for the treatment of resistant hypertension. Despite the availability of multiple classes of orally active antihypertensive treatments, resistant hypertension remains an important public health issue in 2012 due to its prevalence and association with target-organ damage and poor prognosis. The failure of purely pharmacological approaches to treat resistant hypertension has stimulated interest in invasive device-based treatments based on old concepts. In the absence of orally active antihypertensive agents, patients with severe and complicated hypertension were widely treated by surgical denervation of the kidney until the 1960s, but this approach was associated with a high incidence of severe adverse events and a high mortality rate. A new catheter system using radiofrequency energy has been developed, allowing an endovascular approach to renal denervation and providing patients with resistant hypertension with a new therapeutic option that is less invasive than surgery and can be performed rapidly under local anaesthesia. To date, this technique has been evaluated only in open-label trials including small numbers of highly selected resistant hypertensive patients with suitable renal artery anatomy. The available evidence suggests a favourable blood pressure-lowering effect in the short term (6 months) and a low incidence of immediate local and endovascular complications. This follow-up period is, however, too short for the detection of rare or late-onset adverse events. For the time being, the benefit/risk ratio of this technique remains to be evaluated, precluding its uncontrolled and widespread use in routine practice.

Factors Influencing Wound Healing of Critical Ischaemic Foot after Bypass Surgery: Is the Angiosome Important in Selecting Bypass Target Artery? - Corrected Proof

N. Azuma, H. Uchida, T. Kokubo, A. Koya, N. Akasaka, T. Sasajima — 2012-01-11

Abstract: Objectives: The aim of the study is to determine factors affecting ischaemic wound healing and role of the angiosome concept in bypass surgery.Design: Single-centre, retrospective clinical study.Materials and methods: A total of 249 consecutive critical ischaemic limbs with tissue loss in 228 patients who underwent distal bypasses from 2003 to 2009 were reviewed. A total of 81% of patients were diabetic, and 49% of patients had dialysis-dependent renal disease (end-stage renal disease, ESRD). Distal targets of bypasses were the crural artery (57%) and the pedal artery (43%).Results: The complete healing of ischaemic wounds was achieved in 211 limbs (84.7%). ESRD (odds ratio (OR) 0.127, p < 0.001), diabetes (OR 0.216, p = 0.030), Rutherford category 6 (R6) with heel ulcer/gangrene (OR 0.134, p < 0.001), R6 except heel (OR 0.336, p = 0.025) and low albuminaemia (OR 0.387, p = 0.049) were negative predictors of wound healing. Regarding the angiosome, the healing rate in the indirect revascularisation (IR) group was slower than in the direct revascularisation (DR) group, especially in patients with ESRD (p < 0.001). However, the healing rates of the DR and IR groups were similar after minimising background differences with propensity score methods (p = 0.185).Conclusions: In the field of bypass surgery, the angiosome concept seems unimportant, at least in non-ESRD cases. The location and extent of ischaemic wounds as well as co-morbidities may be more relevant than the angiosome in terms of wound healing.

Total Endovascular Repair for Thoraco-abdominal Aneurysms: Not for All, Not for Now - Corrected Proof

P. De Rango — 2012-01-11

Thoraco-abdominal aneurysms (TAAs) represent a surgical challenge due to the complex surgical strategy to extensively replace the visceral aorta preventing multiple-organ ischaemia. The very unlikely opportunity of a mini-invasive approach for TAA, due to the several arterial branch involvement, seems to have become a real therapeutical choice in the last few years. Increasing evidence supports the feasibility of TAA repair with a total endovascular procedure, as shown by the study of Clough et al. in this issue of EJVES reporting the largest experience in the UK with this technique. The authors collected 31 totally endovascular TAA repairs using custom-made endografts in a cohort considered at high-risk for open surgery and achieved early results comparable to those obtained with hybrid or surgical repair in average-risk patients. Thirty-day mortality was 9.7% (3/31) and only one patient (3.1%) presented late-onset paraparesis and a second (3.1%) developed acute renal failure after 8 months. In 32.7% of patients, deterioration of renal function was detected after treatment. There were no conversions to open repair and, of the overall three endoleaks, only one was type III originating from a coeliac bridging stent and requiring reintervention.

Sturge Weber Syndrome with Concomitant Infantile Vein of Galen Aneurysmal Malformation: Role of Multi-modality Imaging in Diagnosis - Corrected Proof

A. Ismail, S.K. Idris, A.M. Tabari, H. Ismail, S. Ali, M. Usman — 2012-01-11

Introduction: Sturge Weber syndrome is a neurocutaneous disorder, characterised by vascular malformation with capillary venous angiomas. Though it presents with vascular anomalies, association with vein of Galen aneurysmal malformation is rare.

Local but not Systemic Capillary Lactate is a Reperfusion Biomarker in Experimental Acute Limb Ischaemia - Corrected Proof

2012-01-11

Abstract: Introduction: Systemic capillary lactate, an end product of cellular anaerobic metabolism, has not established credibility in monitoring limb reperfusion. We assessed, in mice, whether local capillary lactate, arising from the reperfused limb, might be a relevant biomarker of reperfusion.Report: Systemic and local capillary lactate were sampled in the non-ischaemic and in the ischaemic limb. Only local lactate concentrations significantly increased after 2 h of ischaemia and decreased after reperfusion.Discussion: Local, but not systemic, capillary lactate appeared as a potential reperfusion biomarker in this experimental acute limb ischaemia model.

The Strange Relationship between Diabetes and Abdominal Aortic Aneurysm - Corrected Proof

F.A. Lederle — 2012-01-11

In 1995, while preparing the first manuscript on the Aneurysm Detection and Management (ADAM) study ultrasound screening program results, we encountered the remarkable finding that diabetes appeared to reduce the prevalence of abdominal aortic aneurysm (AAA) by almost half. The cohort, 73,451 veterans aged 50–79 years, was an order of magnitude larger than previous similar cohorts, raising the possibility of a new finding, and the effect was seen both with very small aneurysms and with AAA of 4 cm in diameter or larger (). However, AAA was traditionally considered “atherosclerotic” (though arguments had been made to the contrary) and the usual risk factors for atherosclerosis, including diabetes, were assumed to apply. Furthermore, negative associations or ‘protective effects’ between diseases appear to be quite rare, though a few have been reported.

Outcomes after Open Surgery and Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm in Patients with Massive Neck Atheroma - Corrected Proof

2012-01-10

Abstract: Objective: We retrospectively analysed surgically treated abdominal aortic aneurysm (AAA) in patients with massive atheroma in the aneurysmal neck and compared the outcomes of endovascular aneurysm repair (EVAR) and open surgery (OS) to determine an appropriate strategy for massive neck atheroma cases.Methods: A retrospective study was performed in 326 consecutive patients who underwent EVAR and in 247 patients who underwent OS. We defined massive neck atheromas if the following characteristics were observed: (1) thickness ≥ 5 mm; (2) the circumference of the infrarenal aorta ≥ 75%; and (3) length ≥ 5 mm. Twenty-eight patients (8.5%) in the EVAR group and 22 (8.9%) in the OS group met these criteria. We modified the previously published reporting standards on the basis of the selection of systemic and embolisation-related complications.Results: Patients in the EVAR group had less intra-operative blood loss, shorter operation time, and shorter hospital stays after the operation (P < 0.01). No perioperative deaths were observed in either group. Major complications were categorised as early (in-hospital) or late (outpatient, within 6 months). Five and three patients in the OS and EVAR groups had early complications, but the difference was not statistically significant. In contrast, 7 patients in the EVAR group had late complications, compared to no patients in the OS group (P = 0.01). Kaplan–Meier analysis revealed a significantly higher survival rate in the OS group (P = 0.011). Two of the 4 patients with suprarenal clamping developed major complications. Mild eosinophilia was observed in 10 patients in the EVAR group. Proteinuria occurred or worsened in 5 EVAR patients and 1 OS patient.Conclusion: Compared to OS patients, EVAR patients with massive neck atheroma tend to develop late-phase complications possibly related to cholesterol crystal embolisation. The clinical features of massive neck atheroma patients receiving EVAR should be carefully monitored even after hospital discharge.

Nurr1 Haplotypes are Associated with Femoropopliteal Restenosis/Re-occlusion after Percutaneous Transluminal Angioplasty - Corrected Proof

2012-01-10

Abstract: Restenosis/re-occlusion remains a frequent complication in the first year after percutaneous transluminal angioplasty (PTA). In this study, association of nuclear receptor related 1 protein (Nurr1) haplotypes to the restenosis/re-occlusion rate after femoropopliteal PTA was investigated. Patients (n = 142) with disabling claudication or critical limb ischaemia, who had undergone technically successful femoropopliteal PTA, were prospectively followed up by vascular ultrasound imaging 12 months after the procedure. Nurr1 haplotypes 2 and 3 were associated significantly with the restenosis/re-occlusion rate (adjusted odds ratio 1.6, 95% confidence interval (CI) 1.1–2.3 and 2.0, 1.3–2.8, respectively) on univariate analysis.

Prospective Randomised Comparative Study of Visual Foam Sclerotherapy Alone or in Combination with Ultrasound-guided Foam Sclerotherapy for Treatment of Superficial Venous Insufficiency: Preliminary Report - Corrected Proof

T. Yamaki, A. Hamahata, K. Soejima, T. Kono, M. Nozaki, H. Sakurai — 2012-01-10

Abstract: Objective: The aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux.Design and methods: A total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary ‘end’ point of the study was obliteration of the GSV at 6 months.Results: A total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223).Conclusions: These results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.

Comments Regarding ‘Assessment of the Accuracy of AortaScan for Detection of Abdominal Aortic Aneurysm (AAA)’ - Corrected Proof

T. Hartshorne — 2012-01-10

The cost of purchasing ultrasound equipment represents a significant financial burden to abdominal aortic aneurysm (AAA) screening programmes. AAA screening programmes use conventional portable ultrasound scanners equipped with colour flow and spectral Doppler modalities. These modalities are not necessary for routine aneurysm screening, adding to the cost of the equipment. Additionally, they could be potentially misleading if used without appropriate training. The introduction of a simple automated hand-held device would enable AAA screening to be performed by practice nurses and General Practitioners during a routine health check. This would save a considerable amount of money, making AAA screening cheaper and more cost effective. Patients who are suspected of having an AAA can then be offered a rapid confirmation scan using conventional ultrasound in their local imaging department or vascular unit.

The Wonders of a Newly Available Post-analysis CT Software in the Hands of Vascular Surgeons - Corrected Proof

F. Setacci, P. Sirignano, A. Cappelli, C. Setacci — 2012-01-09

Abstract: Introduction: Endovascular treatment of abdominal aortic aneurysms has become a widespread and accepted practice in most Vascular Surgery centres. The optimal method to identify and characterise complications still awaits assessment.Case report: An 83-year-old woman was admitted to our Institution for volumetric expansion of the aneurysm sac due to a suspected type II endoleak. Post-analysis, using OsiriX, revealed the presence of a hole at the distal portion of the main body in the docking zone near the flow divider.Conclusion: OsiriX is an image processing software and an attractive alternative to dedicated workstations and allows rendering and analysis of numerous medical imaging modalities.

Femoral Artery Dissection in Vascular Type Ehlers–Danlos Syndrome; Leave Well Alone? - Corrected Proof

M. Singh, S. Puppala, R.C. Pollitt, G.J. Sobey, D.J.A. Scott — 2012-01-09

Abstract: Vascular Ehlers–Danlos Syndrome (EDS) is a rare autosomal dominant condition resulting from a defect in type III procollagen synthesis. This causes the development of severe vascular pathologies, including arterial rupture and pseudoaneurysm formation. We present a case of a young boy previously diagnosed with vascular EDS due to a Gly975Val substitution in the collagen α1(III) chain presenting with a common femoral artery dissection secondary to minimal trauma. This was managed conservatively with serial duplex scans and gentle mobilization. At follow up the patient had returned to normal activities, with MRA and duplex scans showing complete resolution of the dissection.

Why the United States Center for Medicare and Medicaid Services (CMS) Should not Extend Reimbursement Indications for Carotid Artery Angioplasty/Stenting - Corrected Proof

2012-01-09

A potential crisis looms in the United States of America – related to the proposal for the US Center for Medicare and Medicaid Services (CMS) to allow wider indications for government reimbursement for carotid angioplasty/stenting (CAS). We, the under-signed, are writing to advise CMS to reject this proposal based on overwhelming evidence that it would have serious negative health and economic repercussions for the USA and any other country that may follow such inappropriate action. The purpose of this message is not to advise on existing CMS policy. Instead, we wish to advise that current Medicare coverage for CAS should not be extended to routine practice management of asymptomatic carotid stenosis or symptomatic carotid stenosis where the patient is considered at ‘low/average risk’ of complications from carotid endarterectomy (CEA). We understand that, currently, CMS covers the cost of CAS for the indications listed below (the National Coverage Determination [NCD] for Percutaneous Transluminal Angioplasty [PTA] March 5, 2010):

Commentary to Accompany ‘Removing the need for Cross Matched Blood in Elective EVAR’ - Corrected Proof

J.R. Schneider — 2012-01-09

Dr. Mann and colleagues have presented a clear review of the experience with blood cross matching and transfusion over the 10 year evolution of endovascular aneurysm repair (EVAR) in a single hospital. The total experience in elective EVAR was 203 subjects, but the authors state that their current practice is about 60 cases per year. These numbers are likely comparable to an average general hospital of 250–500 beds and the sample size is clearly adequate to support a careful analysis and conclusions.