Journal of Vascular Surgery

Long-term incidence of myocardial infarct, stroke, and mortality in patients operated on for abdominal aortic aneurysms

2011-11-03

Objective: The risks of myocardial infarction (MI) and stroke after abdominal aortic aneurysm (AAA) resection are not known. Prophylaxis with aspirin and statins is not generally recommended, although patients with AAAs have an increased prevalence of cardiovascular atherosclerosis. We report the incidences of MI, stroke, and death in an unselected national cohort of patients operated on for AAAs, with the general population as the control group. Methods: In a matched cohort study, 11,094 Danish patients who underwent acute or elective open AAA repair from January 1986 through June 2009 were compared with four randomly chosen age- and sex-matched individuals (controls) from the general population (n = 44,364). Data were collected retrospectively from the Danish Vascular Registry (Karbase), the National Population Registry, and the National Inpatient Registry. The groups were analyzed for the incidences of MI, stroke, and death, with up to 20 years of follow-up. Results: AAA patients had an annual MI incidence of 2.5% (hazard ratio, 2.1; 95% confidence interval [CI], 1.9-2.2) compared with the general population. The annual incidence of stroke was 2.9% (hazard ratio, 1.8; 95% CI, 1.6-1.9), and there was a 2.4-fold (95% CI, 2.3-2.4) increase in the hazard of all-cause mortality compared with the general population. Conclusion: AAA patients of both sexes have a high risk of atherosclerotic events (MI, stroke) and death, so lifelong prophylaxis must be considered from our epidemiologic data. Randomized trials investigating the potential benefit of aspirin and statin therapy in AAA patients are needed.

Hybrid repair of thoracic aortic lesions for zone 0 and 1 in high-risk patients

2011-11-03

Purpose: Some patients with aortic arch or descending thoracic aorta pathologies are not suited for open repair because of comorbidities that may increase their risk of procedural complications or death. Endovascular approaches may also be difficult when there are inadequate proximal landing zones in the aortic arch. We report our experience using rerouting techniques with bypass, stenting of the branches, or a combination of both to create a landing area in zones 0 and 1 of the aortic arch. Methods: Since November 2002, thoracic aortic endoluminal grafts were placed in 38 patients in whom the endograft was deployed in zone 0 (n = 27) or zone 1 (n = 11). A retrospective review is included. Results: There were 11 women and 27 men with a mean age of 65.4 years (range 38-88). Aortic pathology included 12 Stanford type A dissections, 10 aortic arch aneurysms, 8 Stanford type B dissections, 3 descending thoracic aortic aneurysms, 2 aortobronchial fistulas, 1 innominate artery aneurysm and 2 aortic arch pseudoaneurysms. In zone 0, 21 had thoracic debranching with an ascending bypass, three patients had a remote-inflow and three patients had a chimney-stent with carotid-carotid bypass. In zone 1, five patients had a carotid-carotid bypass, one patient had an aortic to left common carotid artery (LCCA) bypass and five patients had chimney-stent on the LCCA. Fifty-eight percent of the patients were symptomatic and 26% emergent. Three patients required hemodialysis postoperatively (7.9%), 18 patients (47.4%) required prolonged mechanical ventilation for respiratory insufficiency. Paraplegia occurred in one patient (2.7%), and five patients suffered a cerebrovascular accident (13.1%). There were four early type I and two type II endoleaks. Overall 30-day mortality was 23.7%. Conclusions: The hybrid approach for repair of the aortic arch pathologies is feasible in patients unfit for open repair. We present the results of performing different techniques to treat the aortic arch with hybrid repair with antegrade or retrograde inflow, stenting of the branches or a combination of both. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

Preliminary intraobserver and interobserver variability in wall stress and rupture risk assessment of abdominal aortic aneurysms using a semiautomatic finite element model

2011-11-21

Objective: We investigated the intraobserver and interobserver variability of using semiautomatic finite element analysis to calculate the von Mises stress and peak wall rupture risk (PWRR) in patients with an abdominal aortic aneurysm (AAA) in longitudinal studies. Methods: Four independent observers made 3-dimensional (3D) reconstructions, with minimal manual adjustments, of small AAAs (<5.0 cm) in 17 patients and processed finite element analysis. We used semiautomatic diagnostic software with a finite element model (A4research, VASCOPS GmbH, Graz, Austria). The finite element method was used to calculate von Mises stress and PWRR, which are indicators for wall stress. The differences of each pair of measurements of von Mises stress and PWRR were plotted against their mean and the difference of the mean, according to Bland-Altman analysis. Results: The intraobserver variability had an overall mean percentage difference of 6.86% ± 6.46% for the von Mises stress and 7.70% ± 6.26% for PWRR. The interobserver variability for the four observers showed an overall mean percentage difference of 7.09% ± 6.16% for the von Mises stress and 9.47% ± 8.18% for the PWRR measurement. No significant differences were found (P < .05), for the von Mises stress and PWRR for all observers. Conclusions: The von Mises stress and PWRR of small AAAs calculated in this semiautomatic finite element analysis program show good interobserver and intraobserver variability. It is suitable for clinical use to evaluate mechanical aortic wall characteristics and to compare it with other current methods such as maximum aortic diameter measurements.

Carotid artery aneurysms in patients with human immunodeficiency virus

Vinesh Padayachy, John V. Robbs — 2011-10-03

Objectives: Carotid artery aneurysms, although rare, are increasing in frequency due to their association with human immunodeficiency virus (HIV) disease. Our institution serves a population with a high HIV prevalence and we wished to document our growing experience with this aneurysmal pathology in a setting of an ever-increasing burden of HIV disease. Methods: Data on all patients managed at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, from July 2003 to December 2009 with HIV carotid aneurysms were extracted from a prospective vascular database and their case records were examined. Twenty-two patients were identified of whom 21 had preoperative imaging and underwent some form of intervention. Results: The initial presentation in 19 of the 22 patients was a progressively enlarging neck mass and pain. Ten patients presented with neurology with only 1 patient presenting with a hemiplegia and 1 patient with a monoplegia. Sixteen patients had an open operative repair and 5 patients had an endovascular repair performed as the initial procedure. Of the open procedure, 8 patients had an interposition graft used and 8 had ligation of the common carotid artery (CCA), external carotid artery (ECA), and/or internal carotid artery (ICA). Eighteen patients had no immediate postoperative neurological complications. The worst outcomes were from patients who underwent an endovascular procedure. These included one death, two thrombosed stents, and one endoleak. Histology showed active tuberculosis (TB) in 6 patients who were not known to have TB preoperatively. The overall mortality was 3 of 22 patients. Conclusion: We have noted aneurysms of the carotid artery to occur in patients who are infected with HIV and it seems to be that the incidence of such aneurysms is more common than documented. Open surgical intervention either in the form of an interposition graft or ligation seems to be the more effective treatment option as compared to endovascular stenting. Stenting should be reserved for those patients unfit for open surgery.

Gender-based outcomes after eversion carotid endarterectomy from 1998 to 2009

2011-11-21

Background and Purpose: Although the benefit of carotid endarterectomy (CEA) in reducing the risk of stroke in selected symptomatic and asymptomatic patients has been well documented, the higher incidence of adverse events after CEA for women than for men remains controversial. The purpose of this study was to analyze the effect of female gender on perioperative (30-day) and long-term outcomes after eversion CEA (eCEA). Methods: Patients entered into a prospectively compiled computerized database of all primary consecutive eCEAs performed at our institution from September 1998 to December 2009 were analyzed. Endpoints were perioperative death and stroke, late carotid restenosis or occlusion, and long-term freedom from stroke and survival rates. Long-term follow-up was obtained in 96.8% of patients (97.5% of the women). Results: Among 1294 patients who underwent 1458 eCEAs under general anesthesia with continuous electroencephalographic monitoring and selective shunting, 409 (31.6%) were women (466 eCEAs). More women than men were over 80 years old (P = .001), and female patients were more likely to have arterial hypertension (P = .02) or hyperlipidemia (P = .006) than male patients. Preoperative statin medication (P = .01), contralateral carotid occlusion (P = .02), and shunting use (P = .03) were more frequent among female patients. No perioperative deaths occurred in the series as a whole, while the perioperative stroke risk (0.6% vs 0.5%), and the combined late carotid restenosis and occlusion rate (1.1% vs 0.4%) were comparable between female and male patients. The 7-year stroke-free survival and overall survival rates did not differ significantly between female and male patients (98.3% vs 98.8% and 87.2% vs 93.8%, respectively). Conclusions: This single-center university hospital study shows that although women have a different cardiovascular risk profile from men when they undergo eCEA, there is no evidence of a different gender effect on perioperative and long-term outcomes.

The natural history of duplex-detected stenosis after femoropopliteal endovascular therapy suggests questionable clinical utility of routine duplex surveillance

2011-10-05

Objective: Duplex ultrasound (DU) surveillance (DUS) criteria for vein graft stenosis and thresholds for reintervention are well established. The natural history of DU-detected stenosis and the threshold criteria for reintervention in patients undergoing endovascular therapy (EVT) of the femoropopliteal system have yet to be determined. We report an analysis of routine DUS after infrainguinal EVT. Methods: Consecutive patients undergoing EVT of the superficial femoral artery (SFA) or popliteal artery were prospectively enrolled in a DUS protocol (≤1 week after intervention, then at 3, 6, and 12 months thereafter). Peak systolic velocity (PSV) and velocity ratio (Vr) were used to categorize the treated artery: normal was PSV <200 cm/s and Vr <2, moderate stenosis was PSV = 200-300 cm/s or Vr = 2-3, and severe stenosis was PSV >300 cm/s or Vr >3. Reinterventions were generally performed for persistent or recurrent symptoms, allowing us to analyze the natural history of DU-detected lesions and to perform sensitivity and specificity analysis for DUS criteria predictive of failure. Results: Ninety-four limbs (85 patients) underwent EVT for SFA-popliteal disease and were prospectively enrolled in a DUS protocol. The initial scans were normal in 61 limbs (65%), and serial DU results remained normal in 38 (62%). In 17 limbs (28%), progressive stenoses were detected during surveillance. The rate of thrombosis in this subgroup was 10%. Moderate stenoses were detected in 28 (30%) limbs at initial scans; of these, 39% resolved or stabilized, 47% progressed to severe, and occlusions developed in 14%. Five (5%) limbs harbored severe stenoses on initial scans, and 80% of lesions resolved or stabilized. Progression to occlusion occurred in one limb (20%). The last DUS showed 25 limbs harbored severe stenoses; of these, 13 (52%) were in symptomatic patients and thus required reintervention regardless of DU findings. Eleven limbs (11%) eventually occluded. Sensitivity and specificity of DUS to predict occlusion were 88% and 60%, respectively. Conclusions: DUS does not reliably predict arterial occlusion after EVT. Stenosis after EVT appears to have a different natural history than restenosis after vein graft bypass. EVT patients are more likely to have severe stenosis when they present with recurrent symptoms, in contrast to vein graft patients, who commonly have occluded grafts when they present with recurrent symptoms. The potential impact of routine DU-directed reintervention in patients after EVT is questionable. The natural history of DU-detected stenosis after femoropopliteal endovascular therapy suggests questionable clinical utility of routine DUS.

Heart failure is associated with reduced patency after endovascular intervention for symptomatic peripheral arterial disease

2011-11-03

Objective: Congestive heart failure (CHF) is a highly prevalent comorbidity among patients with symptomatic peripheral arterial disease. The effect of CHF on the procedural success of endovascular treatment, however, remains unknown. Theoretically, poor inflow secondary to systolic dysfunction and peripheral vascular alterations may predispose endovascular interventions to failure. Methods: A retrospective review of a prospectively maintained database was performed to identify CHF patients undergoing endovascular peripheral arterial intervention from 2004 to 2009. Demographics, comorbidities, procedural details, and outcomes were analyzed. Patients underwent duplex ultrasound imaging and clinical follow-up at scheduled intervals. Kaplan-Meier and Cox proportional hazards models were used to evaluate risk factors for loss of primary patency, secondary patency, and limb salvage. Results: Of 1220 patients undergoing intervention, 271 (22%) with documented congestive heart failure (CHF) underwent an intervention for claudication (22.5%) or critical limb ischemia (77.5%). Primary patency at 1 year was 51.9% ± 2.5% among those with CHF vs 64.6% ± 1.3% in those without CHF (P < .001); this disparity continued throughout follow-up (P < .001). Patients with CHF also had reduced secondary patency throughout follow-up. Multivariate analysis showed CHF was an independent predictor of reduced primary patency (hazard ratio [HR], 1.2; 95% confidence interval [CI] 1.0-1.4; P = .038) and secondary patency (HR, 1.5; 95% CI, 1.2-1.8; P < .001). In the setting of CHF, 1-year patency was 56.6% ± 4.1% if the ejection fraction (EF) was >40% (n = 147) vs 43.2% ± 3.5% if the EF was <40% (n = 124; P < .001). Secondary patency was also significantly reduced in patients with EF <40% throughout follow-up compared with patients without CHF (n = 949) as well as those with CHF and EF >40% (P < .001). CHF with EF <40% was an independent predictor of reduced primary patency (HR, 1.4; 95% CI, 1.2-1.8; P < .01) and secondary patency (HR, 1.8; 95% CI, 1.3-2.3; P < .001). Limb salvage was also worse in patients with EF <40% (P = .038). Conclusions: CHF is associated with reduced patency after peripheral endovascular intervention and is an independent risk factor for patency loss. Specifically, CHF and reduced EF (<40%) is a strong independent risk factor for patency loss.

Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions

2011-11-03

Objective: We compared clinical outcomes between limbs with and without achievement of feeding artery flow by endovascular therapy (EVT) based on the angiosome concept in critical limb ischemia (CLI) patients with isolated below-the-knee (BTK) lesions and assessed factors influencing major amputation (MA). Method: We analyzed 369 limbs from 329 consecutive patients (224 men; age, 70 ± 11 years) with ischemic ulceration or gangrene, or both, presenting with isolated BTK lesions (Rutherford class 5, 270 limbs; class 6, 99 limbs) with a pretreatment ankle-brachial index of 0.79 ± 0.26. Patients underwent successful EVT, without bypass surgery. Limbs were classified into direct (n = 200) and indirect (n = 169) groups by whether feeding artery flow to the site of ulceration or gangrene was successfully achieved, based on the angiosome concept. Unadjusted and adjusted (by propensity score matching) between-group rates of amputation-free survival (AFS) and freedom from major amputation (MA) and major adverse limb event (MALE) were compared by Kaplan-Meier analysis and the log-rank test. The independent determinants of MA in the direct and indirect groups were explored by multivariable analysis. Results: During follow-up (mean, 18 ± 16 months), the overall limb salvage rate was 81% (300 of 369), death occurred in 36% (119 of 329), and the reintervention rate was 31% (114 of 369). After propensity score adjustment, the estimated (± standard error) rates for AFS (49% ± 8% vs 29% ± 6%; P = .0002), freedom from MALE (51% ± 8% vs 28% ± 8%, P = .008), and major amputation (82% ± 5% vs 68% ± 5%, P = .01) were significantly higher in the direct group than in the indirect group for up to 4 years after the index procedure. After multivariable Cox proportional analysis, the independent factors associated with major amputation were hemoglobin A1c level (hazard ratio [HR], 1.4; 95% confidential interval [CI], 1.1-1.9; P = .006) and cilostazol administration (HR, 0.28; 95% CI, 0.11-0.70; P = .006) in the direct group, and C-reactive protein level (HR, 1.2; 95% CI, 1.1-1.4; P = .002) in the indirect group. Conclusion: Achieving direct flow by angioplasty based on the angiosome concept in CLI patients with isolated BTK lesions is clinically important for AFS and freedom from MA and MALE. Limb salvage factors appear to differ between patients with and without direct flow from the feeding artery after EVT.

Statin therapy is associated with superior clinical outcomes after endovascular treatment of critical limb ischemia

2011-11-03

Objective: The aim of this study was to determine if statin therapy improves clinical outcomes after endovascular intervention in patients with critical limb ischemia (CLI). Methods: A retrospective review of all patients undergoing endovascular treatment for CLI was performed. Two groups were created according to whether they were receiving statin therapy at the time of intervention. Demographics, lesion morphology, overall mortality, primary and secondary patency, and limb salvage were compared between these groups. Analysis was performed using multivariate regression and Kaplan-Meier analysis. Results: Between 2004 and 2009, 646 patients, 319 receiving statin therapy and 327 without, underwent an endovascular intervention for CLI. The statin group had significantly higher rates of diabetes mellitus, coronary artery disease, congestive heart failure, previous myocardial infarction, and coronary artery bypass grafting (P < .05). The two groups had similar lesion length, location, lesion type, TransAtlantic Inter-Society Consensus (TASC) classification, and primary procedure. At 24 months, the statin-treated group had higher rates of primary patency (43% vs 33%; P = .007), secondary patency (66% vs 51%; P = .001), limb salvage (83% vs 62%; P = .001), and overall survival (77% vs 62%; P = .038). Statin therapy was also independently associated with improved limb salvage by multivariate regression analysis (hazard ratio, 2.55; P < .001). Conclusions: Patients who were receiving statin therapy when they underwent interventions to treat CLI had significantly improved overall survival, primary and secondary patency, and limb salvage rates. Our findings suggest that statins should be part of the periprocedural treatment regimen and support further investigation into the beneficial effects of statins in patients undergoing endovascular treatment of CLI.

Discussion

2011-11-03

Dr Luke Brewster (Decatur, Ga). Thank you very much for the opportunity to discuss this paper, and thank you, Dr Aiello, for giving me the manuscript beforehand. The findings seem clear and well-supported, but unrelated to lipid levels. The average age is 77. It looks like about half the folks are on proper medications prior to undergoing therapy. These are my questions:

A phase II dose-ranging study of the phosphodiesterase inhibitor K-134 in patients with peripheral artery disease and claudication

Eric P. Brass, Leslie T. Cooper, Roger E. Morgan, William R. Hiatt — 2011-11-28

Background: Phosphodiesterase inhibitors have been shown to improve claudication-limited exercise performance in patients with peripheral artery disease. K-134, a novel phosphodiesterase inhibitor, was evaluated in a phase II trial incorporating an adaptive design to assess its safety, tolerability, and effect on treadmill walking time. Design: Patients with peripheral artery disease were randomized to receive placebo (n = 87), K-134 at a dose of 25 mg (n = 42), 50 mg (n = 85), or 100 mg (n = 84), or cilostazol at a dose of 100 mg (n = 89), each twice daily for 26 weeks. Peak walking time (PWT) was assessed using a graded treadmill protocol at baseline and after 14 and 26 weeks of treatment. A Data and Safety Monitoring Board–implemented adaptive design was used that allowed early discontinuation of unsafe or minimally informative K-134 arms. Results: As determined by the prospectively defined adaptive criteria, the 25-mg K-134 arm was discontinued after 42 individuals had been randomized to the arm. During the 26-week treatment period, PWT increased by 23%, 33%, 37%, and 46% in the placebo, 50-mg K-134, 100-mg K-134, and cilostazol arms, respectively (primary analysis placebo vs 100-mg K-134 arm not statistically significant, P = .089). Secondary analyses showed that cilostazol significantly increased PWT after 14 weeks of treatment and that the 100-mg K-134 dose and cilostazol both increased PWT vs placebo after 14 and 26 weeks in those individuals who completed the 26-week trial and were compliant with the study drug, or when the data were analyzed using a mixed-effects model incorporating all time points. K-134 had tolerability and adverse effect profiles similar to that of cilostazol. Both drugs were associated with an increase in withdrawals before study completion due to adverse events compared with placebo. Conclusions: K-134 was generally well tolerated. K-134 at a dose of 100 mg twice daily did not affect PWT according to the primary analysis, but K-134 and cilostazol both increased PWT when analyzed using a mixed-effects model and in the per-protocol population.

Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease

2011-12-15

Objective: Critical limb ischemia, the most severe form of peripheral arterial disease, results in extremity amputation if left untreated. Endovascular recanalization of stenotic or occluded infrapopliteal arteries has recently emerged as an effective form of therapy, although the duration of patency is typically limited by restenosis. Recently, it has been suggested that drug-eluting stents originally developed for the coronary arteries might also be effective in preventing restenosis in the infrapopliteal arteries. This prospective, randomized, controlled clinical trial tested the hypothesis that treatment of infrapopliteal arterial occlusive lesions with an everolimus-eluting stent (Xience V) would provide superior patency to treatment with a bare-metal stent (Multi-Link Vision). Methods: A sample size of 140 patients was planned to be enrolled at five European investigative sites. The primary end point was arterial patency at 12 months, defined as the absence of ≥50% restenosis based on quantitative analysis of contrast angiography. Results: Between March of 2008 and September of 2009, 74 patients were treated with Xience V and 66 patients were treated with Vision. After 12 months, the primary patency rate after treatment with Xience V was 85% compared with 54% after treatment with Vision (P = .0001). Treatment with Xience V significantly reduced mean in-stent diameter stenosis (21% ± 21% vs 47% ± 27%; P < .0001) and mean in-stent late lumen loss (0.78 ± 0.63 vs 1.41 ± 0.89 mm; P = .001). There were no differences in the percentage of patients receiving a designation of Rutherford class 0 or 1 at the 12-month follow-up visit (56% for Vision, vs 60% for Xience V; P = .68). Major extremity amputations were rare in both groups (two for Vision and one for Xience V). The use of the Xience V stent significantly reduced the need for repeat intervention: freedom from target lesion revascularization was 91% for Xience V vs 66% for Vision (P = .001). Conclusions: Treatment of the infrapopliteal occlusive lesions of critical limb ischemia with everolimus-eluting stents reduces restenosis and the need for reintervention compared with bare metal stents.

Invited commentary

Michael. J. Rohrer — 2012-02-01

The increasingly aggressive endovascular management of tibial artery occlusive disease is understandable given the fact that endovascular surgeons have routinely acquired increased technical skill and gained access to enabling endovascular hardware. However, the many options available to treat atheromatous lesions, including balloon angioplasty, cryoplasty, excisional atherectomy, rotational atherectomy, self-expanding stent placement, covered stent placement, balloon expandable stent placement, and drug-eluting stent placement, have driven the treatment of lesions faster than data has provided guidance.

Pharmacokinetic analysis after implantation of everolimus-eluting self-expanding stents in the peripheral vasculature

2011-11-03

Background: A novel self-expanding drug-eluting stent was designed to release everolimus 225 μg/cm2 to prevent restenosis following peripheral arterial intervention. The purpose of this study was to measure the pharmacokinetic profile of everolimus following stent implantation. Methods: One hundred four patients with symptomatic peripheral arterial disease underwent implantation of everolimus-eluting stents in the femoropopliteal arteries. In a prespecified subset of 26 patients, blood samples for assay of everolimus content were collected prior to stent implantation, at 1, 4, and 8 hours postprocedure, prior to discharge, and at 1 month postprocedure. Results: A total of 39 stents, ranging from 28 mm to 100 mm in length, were implanted in 26 patients, resulting in a total delivered everolimus dose range of 3.0 to 7.6 mg. Following the procedure, the maximum observed everolimus blood concentrations (Cmax) varied from 1.83 ± 0.05 ng/mL after implantation of a single 80-mm stent to 4.66 ± 1.78 ng/mL after implantation of two 100-mm stents. The mean time to peak concentration (Tmax) varied from 6.8 hours to 35 hours. The pharmacokinetics of everolimus were dose-proportional in that dose-normalized Cmax and area under the curve values were constant over the studied dose range. Conclusions: After implantation of everolimus-eluting self-expanding stents in the femoropopliteal arteries, systemic blood concentrations of everolimus are predictable and considerably lower than blood concentrations observed following safe oral administration of everolimus.

Efficacy of combined renal and mesenteric revascularization

2011-11-21

Objective: Small numbers of patients have advanced renal and mesenteric vascular disease requiring treatment. Open surgical treatment has been considered high risk, and the advent of endovascular intervention has affected management. This study evaluated the safety and long-term efficacy of concomitant mesenteric and renal revascularization with open techniques. Methods: Data from 90 consecutive patients who underwent mesenteric and renal revascularization during a 30-year period were analyzed. Early and late outcomes were evaluated over two intervals: 48 in period A (1978 to 1995), concomitant open renal and mesenteric revascularization (COR; n = 46) and sequential open renal and mesenteric revascularization (SOR; n = 2); 42 in period B (1996 to 2009), 22 COR, 4 SOR, 13 sequential hybrid open/endovascular repairs (SOER), and 3 sequential endovascular repairs (SER). Results: There were 26 men and 64 women (median age, 67 years). Renal insufficiency was present in 24% and coronary artery disease (CAD) in 53%. Open surgical reconstruction was performed in 126 renal and 149 mesenteric arteries, with angioplasty/stenting in 15 and 8, respectively; 58 patients had concomitant aortic reconstruction (AR), and 9 had prior AR (8 in period A, 1 in period B). Hospital mortality was 8.8% overall; seven (14.5%) in period A and one (2.3%) in period B. Causes of early death were hemorrhage in three and multisystem organ failure in five. During a median follow-up of 4.5 years (range, 6 days-26.5 years), 11 patients progressed to hemodialysis (7 COR, 4 SOER), and 6 had recurrent mesenteric ischemia (4 COR, 1 SOER, 1 SER). Eight patients in period A and seven in period B required further procedures (9 renal, 9 mesenteric; 11 COR, 2 SOER, 1 SOR, 1 SER). Univariate analysis of COR patients showed CAD (P = .017) and prior AR (P = .035), but not concomitant AR (P = .366), predicted early death. Five-year survival for COR patients was 65% overall, but 74% in patients who survived the operation, with no difference between time periods (P = .55). Conclusions: Concomitant open mesenteric and renal revascularization is associated with low early mortality and good long-term durability in appropriately selected patients. It remains a viable procedure, especially in patients requiring concomitant aortic reconstruction. High-risk patients with CAD or prior aortic surgery should be considered for endovascular treatment, when anatomically feasible.

Assessing outcomes to determine whether symptoms related to hypertension justify renal artery stenting

2011-12-02

Objective: The goal of the study was to determine the blood pressure (BP) response to renal artery stenting (RAS) for patients with hypertension urgency, hypertension emergency, and angina with congestive heart failure (angina/congestive heart failure [CHF]). Methods: Patients who underwent RAS for hypertension emergencies (n = 13), hypertension urgencies (n = 25), and angina/CHF (n = 14) were included in the analysis. By convention, hypertension urgency was defined by a sustained systolic BP ≥ 180 mm Hg or diastolic BP ≥ 120 mm Hg, while the definition of hypertension emergency required the same BP parameters plus hypertension-related symptoms prompting hospitalization. Patient-specific response to RAS was defined according to modified American Heart Association reporting guidelines. Results: The study cohort of 52 patients had a median age of 66 years (interquartile range 58-72). The BP response to RAS varied significantly according to the indication for RAS. Hypertension emergency provided the highest BP response rate (85%), while the response rate was significantly lower for hypertension urgency (52%) and angina/CHF (7%; P = .03). Only 1 of 14 patients with angina/CHF was a BP responder. Multivariate analysis showed that hypertension urgency or emergency were not independent predictors of BP response to RAS. Instead, the only independent predictor of a favorable BP response was the number of preoperative antihypertensive medications (odds ratio 7.5; 95% confidence interval 2.5-22.9; P = .0004), which is another indicator of the severity of hypertension. Angina/CHF was an independent predictor of failure to respond to RAS (odds ratio 118.6; 95% confidence interval 2.8-999.9; P = .013). Conclusions: Hypertension urgency and emergency are clinical manifestations of severe hypertension, but the number of preoperative antihypertensive medications proved to be a better predictor of a favorable BP response to RAS. In contrast, angina/CHF was a predictor of failure to respond to stenting, providing further evidence against the practice of incidental stenting during coronary interventions.

Discussion

2011-12-02

Dr Jeffrey Indes (New Haven, Conn). I would like to thank the PVSS for the opportunity to discuss this paper and thank Dr Modrall for giving me the manuscript and for how well written it is. He and his colleagues report the outcomes of renal artery stenting performed as a treatment for hypertensive emergency, urgency, angina, or congestive heart failure (CHF) to determine if these hypertensive symptoms portend to a favorable blood pressure response to renal artery stenosis. Interestingly, in your article you found that four out of 27 patients who had no blood pressure response to stenting derived a significant improvement in estimated glomerular filtration rate (eGFR) after stenting. Conversely, fewer patients derived any improvement in postop eGFR after stenting, specifically 12 of 52 patients, while this increased to 42.3% if their preoperative creatinine was greater than 1.5.

Short- and long-term outcomes of percutaneous transluminal angioplasty/stenting of renal fibromuscular dysplasia over a ten-year period

2011-11-24

Objectives: The purpose of this study was to evaluate short and long-term outcomes of percutaneous transluminal intervention in patients with symptomatic renal artery stenosis due to fibromuscular dysplasia (RAFMD) and/or the combination of RAFMD with aorto-ostial atherosclerotic disease. Methods: A retrospective analysis of all patients with renal artery RAFMD who underwent transcatheter therapy between January 1999 and December 2009 was performed. Blood pressure (BP) measurement, number of BP medications, and hypertension defined by a systolic BP >140 ± diastolic BP >90 were recorded. Renal function was defined by estimated glomerular filtration rate (eGFR). Restenosis was defined by stenosis >60% and was determined by renal artery duplex and/or angiography. Freedom from event (restenosis, renal failure, or recurrent hypertension) was performed using life table analysis. Results: Forty-three procedures were performed on 35 patients with RAFMD. Thirty-two patients (91%) were women, with mean age of 61.9 years old. Technical success was 100% with adjunctive stent placement required in the FMD segment for dissection in 1 patient (2.3%) and in the non-FMD aorto-ostial atherosclerotic lesion in 4 patients (9.3%). Short-term outcomes: the majority (69%) had an immediate clinical benefit for hypertension, 6% were cured without BP medications, and 63% improved with less than or equal to preoperative BP medications. Postintervention, 17% remained at moderately reduced renal function (<60), whereas the percent above >60 mL/minute eGFR increased significantly (from 51% to 69%; P = .002). For the entire cohort, renal function (mean eGFR) significantly increased from 71.9 mL/minute + 5.8 to 80.8 mL/minute + 5.2 (P = .007). Long-term outcomes: freedom from recurrent or worsening hypertension (>140 systolic blood pressure [SBP] and >90 diastolic blood pressure [DBP]) was (93%, 75%, and 41%) and freedom from reduced renal function (eGFR <30 mL/minute) was (100%, 95%, and 64%) at 1, 5, and 8 years, respectively. Patients with reduced baseline renal function (<60 mL/minute) and combined atherosclerotic disease were more likely to experience long-term reduced renal function (eGFR <30 mL/minute; P = .003). Primary and assisted primary patency was (95%, 71%, and 50%) and (100%, 100%, and 100%) at 1, 5, and 9 years, respectively. Conclusion: Renal angioplasty is a safe and durable modality for treating RAFMD with favorable short and long-term clinical outcomes. Patients with combined atherosclerotic disease and FMD were older and were more likely to have declining renal function over time. Early intervention may be imperative to achieve possible cure of hypertension.

Mesenteric/celiac duplex ultrasound interpretation criteria revisited

2011-12-23

Background: Several published studies with a small sample size have reported differing results of duplex ultrasound (DUS) utilizing different threshold velocities in detecting significant stenosis of superior mesenteric (SMA) or celiac arteries (CA). The present study is based on the largest number of mesenteric duplex/angiography correlations reported to date for the diagnosis of SMA/CA stenosis. Methods: One hundred fifty-three patients (151 SMA and 150 CA) had both DUS and arteriography. Receiver operator curves (ROC) were used to analyze peak systolic velocity (PSV), end diastolic velocity (EDV), and SMA or CA/aortic PSV ratio in detecting ≥50% and ≥70% stenosis. Results: For SMA (151 arteries: 84 with ≥50% stenosis [54 of which had ≥70% stenosis] based on angiography): the PSV threshold that provided the highest overall accuracy (OA) for detecting ≥50% SMA stenosis was ≥295 cm/s (sensitivity [sens.] 87%, specificity [spec.] 89%, and OA 88%); and for detecting ≥70% SMA, it was ≥400 cm/s (sens. 72%, spec. 93%, and OA 85%). The EDV threshold that provided the highest OA for detecting ≥50% stenosis was ≥45 cm/s (sens. 79%, spec. 79%, and OA 79%); and for ≥70% stenosis was ≥70 cm/s (sens. 65%, spec. 95%, and OA 84%). ROC analysis showed that PSV was better than EDV and SMA/aortic PSV ratio for ≥50% stenosis of SMA (P = .003 and P = .0005). For celiac arteries (150 arteries: 105 with ≥50% stenosis [62 of which had ≥70% stenosis]): the PSV threshold that provided the highest OA for ≥50% stenosis was ≥240 cm/s (sens. 87, spec. 83%, and OA 86%); and for ≥70% stenosis was ≥320 cm/s (sens. 80%, spec. 89%, and OA 85%). The EDV threshold that provided the highest OA for ≥50% stenosis was ≥40 cm/s (sens. 84%, spec. 48%, and OA 73%); and for ≥70% stenosis was ≥100 cm/s (sens. 58%, spec. 91%, and OA 77%). ROC analysis showed that PSV was better than EDV and SMA/aortic PSV ratio for ≥50% stenosis of CA (P < .0001 and P = .0410.) Conclusions: PSV values can be used in detecting ≥50% and ≥70% SMA/CA stenosis and were better than EDVs and ratios. Previously published data must be validated in individual vascular laboratories. Our results will need prospective validation.

Discussion

2011-12-23

Dr Paul Armstrong (Tampa, Fla). Dr AbuRahma and the vascular group from Charleston have endowed the audience with a contemporary overview of mesenteric duplex ultrasonography. Similar to the presentation today, the accompanying manuscript is well prepared. By means of retrospective analysis, the authors identified a group of patients with clinical features of chronic mesenteric ischemia and constructed data analysis using ROC curves to provide validation for duplex interpretation criteria in the vascular laboratory. The target peak systolic and end diastolic values analyzed in this review included both ≥50% and ≥70% diameter reducing stenosis of the celiac, superior mesenteric and inferior mesenteric arteries. The information derived from their investigation was also compared with some of the classic work done in the field of visceral duplex ultrasonography.

Multicenter assessment of venous reflux by duplex ultrasound

2011-12-19

Objective: This prospective multicenter investigation was conducted to define the repeatability of duplex-based identification of venous reflux and the relative effect of key parameters on the reproducibility of the test. Methods: Repeatability was studied by having the same technologist perform duplicate tests, at the same time of the day, using the same reflux-provoking maneuver and with the patient in the same position. Reproducibility was examined by having two different technologists perform the test at the same time of the day, using the same reflux-provoking maneuver and with the patient in the same position. Facilitated reproducibility was studied by having two different technologists examine the same patients immediately after an educational intervention. Limits of agreement between two duplex scans were studied by changing three elements of the test: time of the day (morning vs afternoon), patient's position (standing vs supine), and reflux initiation (manual vs automatic compression–decompression). Results: The study enrolled 17 healthy volunteers and 57 patients with primary chronic venous disease. Repeatability of reflux time measurements in deep veins did not significantly differ with the time of day, the patient's position, or the reflux-provoking maneuver. Reflux measurements in the superficial veins were more repeatable (P < .05) when performed in the morning with the patient standing. The agreement between the clinical interpretations significantly depended on a selected cut point (Spearman's ρ, −0.4; P < .01). Interpretations agreed in 93.4% of the replicated measurements when a 0.5-second cut point was selected. The training intervention improved the frequency of agreement to 94.4% (κ = 0.9). Alternations of the time of the duplex scan, the patient's position, and the reflux-provoking maneuver significantly decreased reliability. Conclusions: This study provides evidence to develop a new standard for duplex ultrasound detection of venous reflux. Reports should include information on the time of the test, the patient's position, and the provoking maneuver used. Adopting a uniform cut point of 0.5 second for pathologic reflux can significantly improve the reliability of reflux detection. Implementation of a standard protocol should elevate the minimal standard for agreement between repeated tests from the current 70% to at least 80% and with more rigid standardization, to 90%.

Invited commentary

Cynthia K. Shortell — 2012-02-01

This meticulous evaluation of the repeatability and reproducibility of venous duplex imaging by a distinguished group of investigators represents the first phase of the Investigating Venous Evaluation and Standardization of Testing (INVEST) study, the program initiated by the American Venous Forum to develop reporting standards for diagnostic venous studies. Given the extraordinarily widespread use of venous duplex imaging and its critical role in the diagnosis and treatment of chronic venous insufficiency, such standardization is vital for the clinical and research missions associated with this disease.

Combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with CEAP 5 venous disease

2011-11-21

Objective: Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent superficial and/or perforating veins on ulcer recurrence rates in patients with CEAP 5 who have progressive lipodermatosclerosis and impending ulceration. Methods: Endovenous ablation was performed on patients with CEAP 5 disease and incompetent superficial and/or perforator veins and increasing lipodermatosclerosis and/or progressive malleolar pain. A minimum of 3 months of compressive therapy was attempted before endovenous ablation of incompetent veins. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Patients underwent duplex ultrasound scans before ablation to assess for deep, superficial, and perforator venous incompetence as well as postoperatively to confirm successful ablation. Results: Twenty-eight endovenous ablation procedures (superficial = 19; perforator = 9) were performed on 20 patients (limbs = 21). The mean patient age was 73 years old (range, 45-93 years) and the mean body mass index was 29.5 (18.9-58.4). Ninety-five percent of patients previously wore compression stockings (20-30 mm Hg = 9; 30-40 mm Hg = 10; none = 1) for a mean time of 23.3 months (range, 3-52 months) since the prior ulcer healed. Indications for venous ablation were increasing malleolar pain (55%) and/or lipodermatosclerosis (70%). Technical success rates for the ablation procedures were 100% for superficial veins and 89% for perforators (96.4% overall). All patients underwent closure of at least one incompetent vein. Postoperatively, 95% of patients were compliant with wearing compression stockings (20-30 mm Hg = 8; 30-40 mm Hg = 11; none = 1). Ulcer recurrence rates were 0% at 6 months and 4.8% at 12 and 18 months. These data compare with prior studies showing an ulcer recurrence rate up to 67% at 12 months with compression alone. Conclusion: Patients with CEAP 5 healed venous ulcers that undergo endovenous ablation of incompetent superficial and perforating veins and maintain compression have reduced ulcer recurrence rates compared with historical controls that are treated with compression alone.

Long-term results of a randomized controlled trial on ultrasound-guided foam sclerotherapy combined with saphenofemoral ligation vs standard surgery for varicose veins

2011-11-21

Background: The long-term results of a prospective, randomized controlled trial in patients with primary varicose veins are reported. Methods: Saphenofemoral ligation (SFL) was done in 73 patients (82 legs). In addition, 43 (23 women; age, 47) underwent stripping and multiple phlebectomies under general anesthesia (group S), and 39 (32 women; age, 49) had concurrent sclerotherapy under local anesthesia (group F). Assessments included CEAP C status, Venous Clinical Severity Score (VCSS), Venous Segmental Disease Score (VSDS), Aberdeen Varicose Vein Questionnaire (AVVQ), and 36-Item Short-Form (SF-36) scores. Results: CEAP C was similar between groups (C2-6). In group S, 40% of legs required 25 additional foam sessions (mean volume, 11 mL). In group F, 47.5% of legs required 33 sessions (mean volume, 9 mL) The groups had equivalent preoperative VCSS scores and similar changes at 3 (P = .504) and 5 years (P = .484), as were the absolute VCSS scores at 3 (P = .313) and 5 years (P = .104; Mann-Whitney U). The VSDS score improved (median [interquartile range]) preoperatively vs 3 years (group S, 16.32 [14.7] vs 8.94 [11.51], P = .003; group F, 12.28 [10.37] vs 4.97 [6.19]; P < .0005, Wilcoxon). Above knee obliteration occurred in 17 of 26 (65.4%) for group S and in 16 of 33 (48.5%) for group F at 3 years, and in 14 (53.8%) and 19 (57.6%) at 5 years. AVVQ scores were similar before and at 3 years (P = .703) but significantly favored group S at 5 years (P = .015; Mann-Whitney U). The AVVQ also improved within both groups. The SF-36 mental summary score over 3 years deteriorated in group S (P = .04). However, the physical summary scores did not change between groups (S, P = .361; F, P = .889) or the mental score in group F (P = .285). Changes in the physical (P = .724) and mental (P = .354, Mann-Whitney U) scores did not differ between the groups due to treatment. Conclusion: At 3 and 5 years of follow-up, the treatment was equally effective in the surgical and foam groups, as demonstrated with VCSS, VSDS, and the SF-36 physical component score. At 5 years, the AVVQ was significantly better in the surgical group. The additional foam sessions were also similar. Because traditional surgery for varicose veins does not provide a definitive treatment, foam sclerotherapy could be offered as in a dental care treatment model: “treat as and when the problem appears.”

The impact of ablation of incompetent superficial and perforator veins on ulcer healing rates

2011-12-01

Objective: We assessed the impact of endovenous ablation of incompetent superficial (great saphenous [GSV] and small saphenous [SSV]) and perforator (posterior tibial [PTPV]) veins on the healing rate of venous ulcers in patients who had failed conventional compression therapy. Methods: Patients with CEAP 6 ulcers were treated with weekly compression in a dedicated wound care center. Ulcer size and depth were tracked prospectively. Those ulcers that showed no measurable improvement after >5 weeks of compression therapy underwent ablation of at least one incompetent vein. Results: We performed 140 consecutive endovenous ablation procedures (74 superficial and 66 perforator) on 110 venous ulcers in 88 limbs. Ulcers had been present for 71 ± 6 months with an initial ulcer area of 23 ± 6 cm2. Following successful ablation, the healing rate for healed ulcers improved from + 1.0 ± .1 cm2/month to −4.4 ± .1 cm2/month (P > .05). Ulcer healing rate for healed ulcers, based on the last vein ablated, was GSV = 6.4 cm2/month, SSV = 4.8 cm2/month, and PTPV = 2.9 cm2/month. After a minimum observation period of 6 months (mean follow up, 12 ± 1.25 months), 76.3% of patients healed in 142 ± 14 days. Twelve patients with 26 ulcers did not heal: two patients died from unrelated illnesses, six patients are still actively healing, and four patients have been lost to follow up. Of the healed ulcers, four patients with six ulcers (7.1%) recurred; two have rehealed. Conclusion: There is measurable and significant reduction in ulcer size and ultimate healing following ablation of incompetent superficial and perforator veins in patients who have failed conventional compression therapy.

Endovascular treatment combined with emboloscleorotherapy for pelvic arteriovenous malformations

2011-11-03

Purpose: To describe the clinical features and treatment outcomes after combined endovascular and embolosclerotherapy treatment of pelvic arteriovenous malformations (AVMs). Methods: From November 1996 to May 2011, we treated 12 patients (seven males, five females; mean age, 38.1 ±14.6 years; age range, 23-70 years) with pelvic AVMs. Our treatment strategy was coil embolization of a dilated draining vein of the AVM to reduce blood flow velocity in the AVM lesion and sclerotherapy of the residual arteriovenous fistulae with high-concentration ethanol to eradicate potential AVM recurrence. To ensure effective endovascular treatment, we used transarterial, transvenous, percutaneous, or combined access routes. Treatment outcomes were assessed with periodic computed tomography angiograms and clinical examinations. Results: During the follow-up period (mean, 33.2 months; median, 21.3 months; range, 1-96 months) after embolosclerotherapy, we observed complete remission (no residual or recurrent AVM lesion on follow-up computed tomography and complete symptomatic relief) in 10 (83.3%) patients and partial remission in two (16.7%) patients. One major complication of focal bladder necrosis occurred (1/22 sessions, 4.5%, 1/12 patients, 8.3%), but this resolved with conservative treatment. As early procedure-related complications, transient pulmonary hypertension and/or hemoglobinuria developed in 54.5% (12/22 sessions) and 22.7% (5/22 sessions) of patients, respectively. Conclusions: Combined embolosclerotherapy of pelvic AVMs with coils and ethanol was efficacious at achieving complete remission.

Balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenoses of hemodialysis grafts after surgical thrombectomy

2011-12-19

Objective: Most arteriovenous hemodialysis grafts fail ≤18 months after implantation, most commonly due to intimal hyperplasia at the venous anastomosis. This open prospective study compared balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenosis after thrombectomy of prosthetic brachial-axillary accesses. Methods: Between February 2007 and December 2010, 61 patients with an initial thrombosis of a prosthetic brachial-axillary access were admitted to our hospital. Of these patients, 28 (46%), treated before June 2008, underwent thrombectomy plus balloon angioplasty of the venous anastomosis (group A), whereas the remaining 33 (54%) patients, who were treated after July 2008, underwent graft thrombectomy plus angioplasty with self-expanding nitinol stent placement (group B). Primary, primary-assisted, and secondary patency rates were calculated using Kaplan-Meier analysis and compared between the two groups with the log-rank test. Results: Primary patency was 32% at 3 months, 24% at 6 months, and 14% at 12 months in group A, and the respective values were 85%, 63% and 49% in group B. Primary patency was significantly better in group B than in group A (P < .001; log-rank test). Cumulative median patency was 60 days in group A and 260 days in group B. Patient age, sex, comorbidities, graft material, and graft age did not have prognostic significance. Primary-assisted and secondary patency rates were significantly higher in group B. Conclusions: Graft thrombectomy plus angioplasty with self-expanding nitinol stent placement provides significantly higher patency rates compared with thrombectomy plus plain balloon angioplasty of the venous anastomosis.

Polydeoxyribonucleotide restores blood flow in an experimental model of ischemic skin flaps

2011-11-04

Background: Ischemia is a major factor contributing to failure of skin flap surgery, which is routinely used for coverage of wounds to prevent infection and to restore form and function. An emerging concept is that adenosine A2A receptors can improve tissue oxygenation by stimulating angiogenesis, likely through vascular endothelial growth factor (VEGF). This study assessed the ability of polydeoxyribonucleotide (PDRN) to restore blood flow and improve wound healing, acting through the A2A receptor, in a rat model of ischemic skin flaps. Methods: The H-shaped double-flap model was used in male Sprague-Dawley rats. After surgical procedures, the animals were randomized to receive intraperitoneal PDRN (8 mg/kg) or vehicle (NaCl 0.9%). Rats were euthanized 3, 5, and 10 days after skin injury, after the evaluation of skin perfusion by laser Doppler. The wounds underwent histologic analysis and were measured for VEGF messenger RNA and protein expression, hypoxia inducible factor-1-α (HIF-1α), and inducible nitric oxide synthase (iNOS) protein expression, and nitrite content. Results: Blood flow markedly increased in blood flow in ischemic flaps treated with PDRN, with a complete recovery starting from day 5 (ischemic flap + vehicle, 1.80 ± 0.25; ischemic flap + PDRN, 2.46 ± 0.25; P < .001). Administration of PDRN enhanced the expression of VEGF (ischemic flap + vehicle, 5.3 ± 0.6; ischemic flap + PDRN, 6.2 ± 0.5; P < .01) at day 5, and iNOS (ischemic flap + vehicle, 3.9 ± 0.6; ischemic flap + PDRN, 5.3 ± 1; P < .01), but reduced HIF-1α expression (ischemic flap + vehicle, 7 ± 1.1; ischemic flap + PDRN, 4.8 ± 0.5; P < .05) at day 3. Histologically, the PDRN-treated group showed complete re-epithelialization and well-formed granulation tissue rich in fibroblasts. Conclusions: These results suggest that PDRN restores blood flow and tissue architecture, probably by modulating HIF-1α and VEGF expression, and may be an effective therapeutic approach in improving healing of ischemic skin flaps. Clinical Relevance: Future therapies aimed at the enhancement of flap viability in vascular and reconstructive surgery, as well as to achieve a faster wound repair and angiogenesis under ischemic conditions, should include the stimulation of the adenosine A2A receptor. This report provides evidence of an agent that may have clinical use to decrease the risk of flap ischemia.

Hypercholesterolemia and oxidative stress inhibit endothelial cell healing after arterial injury

Michael A. Rosenbaum, Keiko Miyazaki, Linda M. Graham — 2011-11-03

Objective: Endothelial cell (EC) migration is essential for arterial healing after angioplasty. Oxidized low-density lipoproteins and oxidative stress decrease EC migration in vitro. The objective of this study was to determine the effect of hypercholesterolemia and oxidative stress on EC healing after an arterial injury. Methods: C57BL/6 wild-type mice were placed in one of eight groups: chow diet (n = 11), high-cholesterol (HC) diet (n = 11), chow diet plus paraquat (n = 11), HC diet plus paraquat (n = 11), chow diet plus N-acetylcysteine (NAC) (n = 11), HC diet plus NAC (n = 11), chow diet plus paraquat and NAC (n = 11), and HC diet plus paraquat and NAC (n = 11). After 2 weeks on the assigned diet with or without NAC, the carotid artery was injured using electrocautery. Animals in the paraquat groups were given 1 mg/kg intraperitoneally to increase oxidative stress. After 120 hours, Evans Blue dye was infused intravenously to stain the area of the artery that remained deendothelialized. This was used to calculate the percentage of re-endothelialization. Plasma and tissue samples were analyzed for measures of oxidative stress. Results: The HC diet increased oxidative stress and reduced EC healing compared with a chow diet, with EC covering 26.8% ± 2.8% and 48.1% ± 5.2% (P < .001) of the injured area, respectively. Administration of paraquat decreased healing in both chow and HC animals to 18.1% ± 3.5% (P < .001) and 9.8% ± 4.6% (P < .001), respectively. Pretreatment with NAC (120 mmol/L in drinking water) for 2 weeks prior to injury, to decrease oxidative stress, improved EC healing to 39.9% ± 5.7% (P < .001) in hypercholesterolemic mice and to 30.7% ± 3.6% (P < .001) in the paraquat group. NAC treatment improved healing to 24.6% ± 3.4% (P < .001) in hypercholesterolemic mice treated with paraquat. Conclusion: Re-endothelialization of arterial injuries is reduced in hypercholesterolemic mice and is inversely correlated with oxidative stress. An oral antioxidant decreases oxidative stress and improves EC healing. Clinical Relevance: Vascular injury following cardiovascular intervention, including cardiac and peripheral arterial angioplasty and stenting, is associated with inflammation and oxidative stress. Hypercholesterolemia is also associated with increased oxidative stress. Oxidative stress, regardless of the source, induces cellular dysfunction in endothelial and smooth muscle cells that reduce healing after arterial injury. Decreasing oxidative stress with an exogenously administered antioxidant can improve endothelial cell healing, and this is important to control intimal hyperplasia and reduce the thrombogenicity of the vessel.

Remote and local ischemic preconditioning equivalently protects rat skeletal muscle mitochondrial function during experimental aortic cross-clamping

2011-11-07

Objective: This study investigated whether remote (rIPC) and local ischemic preconditioning (IPC) similarly limit skeletal muscle dysfunction induced by aortic cross-clamping. Methods: Rats were divided in three groups: the sham-operated control group (C) underwent surgery without clamping. The ischemia-reperfusion group (IR) had 3 hours of ischemia induced by aortic clamping and collateral vessels ligation, followed by 2 hours of reperfusion. The IPC group had, before prolonged ischemia, three bouts of 10 minutes of ischemia and 10 minutes of reperfusion on the right hind limb. Thus, right hind limbs had local IPC and left hind limbs had rIPC. Complexes I, II, III, and IV activities of the mitochondrial respiratory chain of the gastrocnemius muscle were measured using glutamate-malate (Vmax), succinate (Vsucc), and N,N,N′,N′-tetramethyl-p-phenylenediamine dihydrochloride (TMPD)-ascorbate (VTMPD). Expressions of genes involved in apoptosis (Bax, Bcl-2) and antioxidant defense (superoxide dismutase 1 [SOD 1], SOD2, glutathione peroxidase [GPx]) were determined by quantitative real-time polymerase chain reaction. Glutathione was also measured. Results: Right and left hind limb mitochondrial functions were similar in controls and after IR. IR reduced Vmax (–21.2%, 6.6 ± 1 vs 5.2 ± 1 μmol O2/min/g dry weight, P = .001), Vsucc (–22.2%, P = .032), and VTMPD (–22.4%, P = .033), and increased Bax (63.4%, P = .020) and Bax/Bcl-2 ratio (+84.6%, P = .029). SODs and GPx messenger RNA were not modified, but glutathione tended to be decreased after IR. Local IPC and rIPC counteracted similarly these deleterious effects, restoring mitochondrial maximal oxidative capacities and normalizing Bax, the Bax/Bcl-2 ratio, and glutathione. Conclusions: Remote ischemic preconditioning protection against IR injury is equivalent to that achieved by local IPC. It might deserve a broader use in clinical practice. Clinical Relevance: Acute and chronic ischemia induce mitochondrial dysfunction in human skeletal muscles, and improving muscle mitochondrial function improves subjects' status. Compared with local ischemic preconditioning (IPC), remote IPC (rIPC) appears easier to perform and is safer for the vessel and territory involved in ischemic injury. This study demonstrates that the muscle protection afforded by rIPC is equivalent to that achieved by IPC. Acknowledging that IPC procedures should be specifically adapted to patient characteristics to be successful, our results support a broader use of rIPC in the setting of vascular surgery.

Cilostazol suppression of arterial intimal hyperplasia is associated with decreased expression of sialyl Lewis X homing receptors on mononuclear cells and E-selectin in endothelial cells

2012-02-01

Background: An inflammatory reaction in vascular tissue is a potential factor linking restenosis after angioplasty. Although cilostazol, a selective phosphodiesterase type 3 inhibitor that is a unique antiplatelet drug and vasodilator, has been reported to be anti-inflammatory, its effect on the inflammatory action of mononuclear cells homing to endothelial cells is not clearly understood. In this study, whether cilostazol inhibits neointimal formation and improves inflammatory actions by inhibiting sialyl Lewis X (SLX) expression on mononuclear cells and E-selectin expression on endothelial cells was evaluated. Methods: The effect of cilostazol (1, 3, 10, 30 μM) on expression of E-selectin in human umbilical vein endothelial cells and SLX in rat mononuclear cells stimulated with lipopolysaccharide by immunofluorescence and real-time polymerase chain reaction (n = 3) was studied. Additionally, a double-balloon injury model was used on rat carotid arteries to evaluate vascular intimal hyperplasia. 0.1% cilostazol was administered 3 days before the first balloon injury, and the second balloon injury was performed 7 days after the first injury. Cilostazol administration was continued until rats were sacrificed 14 days after the second angioplasty. The expression of SLX on mononuclear cells and E-selectin on endothelial cells by immunofluorescence (n = 10) and real-time polymerase chain reaction (n = 5) were studied. Results: Cilostazol effectively inhibited the expression of SLX on mononuclear cells and E-selectin on endothelial cells. Cilostazol inhibited the migration of mononuclear cells in neointimal regions and neointimal hyperplasia after balloon injury. The numbers of macrophages and T-lymphocytes and the hyperplasia area in neointimal regions decreased from 71.06 ± 20.04, 1121 ± 244.4 cells per section, 206,400 ± 96,150 mm2 to 29.65 ± 16.73, 374.2 ± 124.5 cells per section, and 101,900 ± 16,150 mm2 due to the administration of cilostazol. Conclusions: These results demonstrate that the protective effect of cilostazol against neointimal hyperplasia may be mediated by its anti-inflammatory actions of mononuclear cells homing to endothelial cells by decreasing SLX and E-selectin expression. Clinical Relevance: It is reported that cilostazol inhibits neointimal hyperplasia by decreasing the expression of some cell-adhesion molecules. We evaluated the effects of cilostazol for the expression of sialyl Lewis X (SLX) on mononuclear cells and E-selectin on endothelial cells, which interaction is the first step of inflammation action. Cilostazol was thought to show the anti-inflammatory actions by decreasing SLX and E-selectin expression in addition to decreasing the expression of some cell-adhesion molecules.

Sugarcane biopolymer patch in femoral vein angioplasty on dogs

2011-09-05

Purpose: To evaluate the use of the sugarcane biopolymer membrane in femoral vein patch angioplasty on dogs. Methods: Eight dogs were submitted to bilateral femoral vein patch angioplasty with a sugarcane biopolymer membrane patch on one side and an expanded polytetrafluoroethylene (e-PTFE) patch on the contralateral side. This research was performed at Experimental Surgical Research Laboratory of the Centro de Ciências da Saúde at Universidade Federal de Pernambuco. The dogs underwent new surgery at 180 days after the patch angioplasty in order to harvest the femoral vein. All the animals were evaluated by clinical examination, measure of femoral vein diameter, venogram, and Doppler fluxometry. The material harvested was sent for histologic study. Each animal served as its own control. Results: In all veins of both groups, there were no cases of infection, rupture, or pseudoaneurysm formation and thrombosis. In both groups, a chronic inflammatory reaction was observed, with lymphocytes, neutrophils, and fibrosis in the outer surface of the patches. Fibrosis was seen in the inner surfaces of all the patches. In e-PTFE patches, invasion by fibroblasts occurred. Conclusions: The sugarcane biopolymer membrane can be used as a patch in femoral vein angioplasty on dogs. Clinical Relevance: The sugarcane biopolymer membrane is easily synthesized with a low cost of production. This membrane has been used in many areas of experimental surgery as in the healing of skin wounds, in urinary reconstruction, in reconstruction of tympanic membrane, and as an arterial substitute, but there is no report of its use as a vein substitute. In order to evaluate the possibility of using the sugarcane biopolymer membrane in venous reconstructive surgery, this study analyzed its utilization in femoral vein patch angioplasty.

Adventitial cystic disease of the femoral vein in a 5-year-old boy mimicking deep venous thrombosis

Douglas W. Jones, Combiz Rezayat, Patricia Winchester, John K. Karwowski — 2011-09-14

Adventitial cystic disease of the vein is a rare vascular anomaly with 32 reported cases. A 5-year-old boy initially presented with painless leg swelling. He was misdiagnosed with deep vein thrombosis and treated with 3 months of warfarin. When swelling failed to improve, a magnetic resonance venogram showed a mural cystic lesion of the left common femoral vein. In the operating room, the cyst was excised, relieving the obstructive effect and restoring flow. The swelling resolved within days. This is the first reported case of adventitial cystic disease of the vein occurring in a pediatric patient.

Early diagnosis and resection of an asymptomatic leiomyosarcoma of the inferior vena cava prior to caval obstruction

2011-10-05

Leiomyosarcoma of the inferior vena cava is a rare and aggressive tumor, characterized by a slow growth and usually late diagnosis. The mainstay of therapy is surgical resection with limited role for chemotherapy or radiotherapy; resection modalities and the need for caval reconstruction are still matters of debate. In this case report, we describe an asymptomatic intraluminal leiomyosarcoma of the inferior vena cava diagnosed incidentally prior to caval occlusion during a routine ultrasound examination of the upper abdomen.

Case of the disappearing heat-induced thrombus causing pulmonary embolism during ultrasound evaluation

Shekeeb Sufian, Alejandro Arnez, Sanjiv Lakhanpal — 2011-09-29

We report a case of a 58-year-old male patient who underwent successful endovenous radiofrequency ablation of the left great saphenous vein for CEAP class 4a venous disease. On the third postoperative day, he had a duplex ultrasound scan for evaluation which showed successful occlusion of the great saphenous vein (GSV) with class 2 endovenous heat-induced thrombus (EHIT) that disappeared during the evaluation and caused a pulmonary embolism. To our knowledge, no case of pulmonary embolism has been reported to occur during postoperative follow-up duplex scanning. Relevant literature is reviewed and a possible mechanism for thrombus dislodgement is entertained.

Endovascular management of ruptured infected popliteal artery aneurysm

2011-09-29

Infected popliteal aneurysm is a rare high-risk condition that can present as an emergency with acute rupture and sepsis. Management of acute ischemia in the presence of local and systemic sepsis is challenging. Open surgery is not always possible and carries a high risk of morbidity and death. An endovascular approach has been advocated in infected aneurysms elsewhere in the body, with good short-term and medium-term outcomes encouraging such approach in the popliteal artery. We report a case of successful endovascular treatment of an infected ruptured popliteal aneurysm with favorable outcome after 2-year follow-up and a related review of the literature.

Shotgun wound and pellet embolism to the intracranial carotid artery

2011-10-03

Missile embolism into the cerebral circulation is a very unusual complication of shotgun wounds to the chest or neck. We report a case of an 11-year-old boy who sustained an air gunshot wound and pellet embolism to the intracranial carotid artery. The cerebral artery pellet embolus resulted in contralateral hemiplegia. The patient was successfully treated by emergency flow reversal and embolectomy. Because this injury is extremely rare, the literature is reviewed, and several principles are suggested to improve the management.

Surgical conversion for intragraft thrombosis following endovascular repair of traumatic aortic injury

2011-09-26

We report the case of a 32-year-old man with severe polytrauma, submitted to urgent endovascular exclusion of a posttraumatic thoracic aortic pseudoaneurysm. Two years later, computed tomography scan showed asymptomatic mural atherothrombosis of the aortic stent graft in its middle-distal portion, and the patient was placed on oral anticoagulants. As subsequent computed tomography scan showed progression of the thrombosis, the patient underwent surgical conversion, with stent graft explantation and in situ aortic replacement. Gross examination revealed mural organized thrombosis and a significant infolding of the distal end of the stent graft.

Covered stent use after subclavian artery and vein injuries in the setting of vascular Ehlers-Danlos

2011-09-29

Vascular Ehlers-Danlos (VED) represents a rare disorder in which a defect in collagen synthesis renders vessels to be extremely fragile. We report the successful repair of a subclavian artery pseudoaneurysm via a hybrid technique employing delivery of a covered stent along with video-assisted thoracoscopic ligation of the internal mammary artery in a patient with VED.

Two cases of tracheoinnominate artery fistula following tracheostomy treated successfully by endovascular embolization of the innominate artery

Shingo Hamaguchi, Yasuo Nakajima — 2011-09-29

Tracheoinnominate artery fistula (TIF) is a rare but lethal complication of tracheostomy. Treatment has traditionally been surgical, but advances in endovascular technology have led to a few recent reports of therapy with coils. We report 2 cases of TIF with massive hemorrhage that underwent successful treatment with endovascular occlusion. Endovascular repair is less invasive than open surgical repair and usually associated with a shorter recovery period. However, this technique may require multiple coils to inhibit blood flow into the fistula. This procedure should be considered one of the useful treatments for TIF.

Chronic contained rupture of an abdominal aortic aneurysm manifesting as lower extremity neuropathy

Hideki Tsubota, Tomohiro Nakamura — 2011-04-01

A 60-year-old man presented with intense right knee and thigh pain as well as weakness in his right lower extremity. Two months prior, he had sudden onset of severe low back pain and presented to his local physician, where he was diagnosed with lumbar spondylolisthesis. The back pain remitted soon thereafter, but he subsequently developed right knee and thigh pain. Upon presentation to our hospital, he denied having lower back pain or abdominal pain and had intact pulses in his lower extremities. His abdomen was soft and without tenderness, but a pulsating mass was palpated in the periumbilical region.

A giant true aneurysm of the celiac trunk

Nicola Troisi, Giovanni Esposito, Elisa Peretti, Marco Setti — 2012-02-01

A 80-year-old man was admitted to our department because of an arterial dilatation into the abdomen recorded during a routine ultrasound scan. His medical history was notable for smoking, chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, and atrial fibrillation in anticoagulant therapy. The patient never underwent abdominal surgery and he was asymptomatic for abdominal pain.

The controversy of managing calf vein thrombosis

2011-10-28

Background: Controversy persists as to whether all calf vein thrombi should be treated with anticoagulation or observed with duplex surveillance. We performed a systematic review of the literature to assess whether data could support either approach, followed by examination of its natural history by stratifying results according to early clot propagation, pulmonary emboli (PE), recurrence, and postthrombotic syndrome (PTS). Methods: A total of 1513 articles were reviewed that were published from January 1975 to August 2010 using computerized database searches of PubMed, Cochrane Controlled Trials Register, and extensive cross-references. English-language studies specifically examining calf deep vein thrombosis (C-DVT) defined as axial and/or muscular veins of the calf, not involving the popliteal vein, were included. Papers were independently reviewed by two investigators (E.M., F.L.) and quality graded based on nine methodologic standards reporting on four outcome parameters. Results: Of the 1513 citations reviewed, 31 relevant papers meeting predefined criteria were found: six randomized controlled trials (RCT) and 25 observational cohort studies or case series. There was a single RCT directly comparing anticoagulation with no anticoagulation with compression and duplex surveillance, and they found no difference in propagation, PE, or bleeding in a low-risk population. Based on two studies of moderately strong methodology, C-DVT propagation was reduced with anticoagulation. When treatment was unassigned, moderately strong evidence suggested that about 15% propagate to the popliteal vein or higher. However, based on nonrandomized data but with moderate to high quality (level A and B studies), propagation to popliteal or higher was 8% in those with no anticoagulation treated with surveillance only. Propagation involving adjacent calf veins but remaining in the calf occured in up to one-half of all those who propagate. Major bleeding was an intended endpoint in three RCTs and was reported as 0% to 6%, with a trend toward lower bleeding risk in more recent studies. PE during surveillance in studies with unassigned treatment was strikingly lower than the historical reports of PE recorded at presentation, emphasizing the distinction that must be made between the two entities. Recurrence in C-DVT is lower than thigh DVT, and data suggest that in low-risk groups with transient risk factors, 6 weeks of anticoagulation may be sufficient, as opposed to 12 weeks. Studies of PTS reported that patients with C-DVT had fewer symptoms than their thigh DVT counterparts. Approximately one out of 10 showed symptoms of CEAP Class 4 to 6; however, C5 or C6 with healed or active ulceration were not commonly encountered. Conclusions: No study of strong methodology could be found to resolve the controversy of optimal treatment of C-DVT. Given the risks of propagation, PE, and recurrence, the option of doing nothing should be considered unacceptable. In the absence of strong evidence to support anticoagulation over imaging surveillance with selective anticoagulation, either method of managing calf DVT must remain as current acceptable standards.

The identification and management of heparin-induced thrombocytopenia in the vascular patient

Glenn M. LaMuraglia, Rabih Houbballah, Michael Laposata — 2011-12-22

Heparin-induced thrombocytopenia (HIT) is a serious, acquired, prothrombotic disorder caused by an antibody response to the heparin-platelet factor 4 complex, which can precipitate arterial as well as venous thromboembolic complications. HIT should be suspected in patients exposed to heparin who present with an unexplained thrombosis or a significant drop in platelet count, or both. Once HIT is suspected or identified, there are specific approaches to its diagnosis and management, with emphasis on removal of all heparin compounds and administration of alternative nonheparin anticoagulants. Generally, HIT is a self-limiting syndrome that resolves when the antibody titers disappear. Patients should be anticoagulated for up to 6 months, depending on the clinical scenario; however, the management of patients with remote or recent HIT requiring a vascular procedure requires special considerations.

Vascular Lab 360: Are we losing control?

Ali F. AbuRahma — 2012-02-01

“Only one who devotes himself to a cause with his whole strength and soul can be a true master. For this reason mastery demands all of a person”–Albert Einstein It is with the greatest honor that I stand before you today as president of the Eastern Vascular Society on this special 25th Anniversary of the society. This society has been very special to me since I joined 21 years ago, and I have not missed one single meeting since I joined in 1990. The Eastern Vascular Society was founded in 1987 by leaders in vascular surgery on the east coast of the United States, who have led the way in our society and played a prominent role in the leadership of our national Society for Vascular Surgery (SVS). In looking at the names of our past presidents, eight of them have served as president of the SVS/American Association for Vascular Surgery. It should also be noted that from the current officers of the Society for Vascular Surgery, the president, the vice-president, secretary, and the treasurer are current members of the Eastern Vascular Society.

Ethics of treating postoperative pain

James W. Jones, Laurence B. McCullough — 2012-02-01

You received a call advising that Mr S. H. Irk was in the emergency room having considerable wound pain following an above-knee amputation you performed 6 months ago. You discharged him from your clinic 6 weeks postoperatively to his primary care physician, still complaining of more pain than usual. Your examination, clinical lab tests, and X-rays do not reveal any serious problems, but he is writhing in pain and begging for relief. Mr Irk has been to a number of different physicians in the interlude including a chiropractor, a pain specialist, several primary care physicians, and a psychiatrist without relief. He has braced up with increasing amounts of analgesics, the latest of which was oral Dilaudid. His last source of pain meds on the street has dried up. You admit him with orders for analgesics. What should your treatment plan be?

Cost implications of more widespread carotid artery stenting consistent with the American College of Cardiology/American Heart Association Guideline

Kosmas I. Paraskevas, Wesley S. Moore, Frank J. Veith — 2011-12-22

The recent American College of Cardiology/American Heart Association guideline recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients. This and the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) form the basis for seeking more liberalized indications and reimbursement for CAS. For the years 2005-2007, >130,000 carotid interventions/year were performed, 88.6% of which were CEAs and 11.4% were CAS. For the same years, each CAS procedure had on average $12,000-$13,500 more expensive mean total hospital charges than each CEA. If the percentages of CAS and CEA had been equal (ie, 50% CAS and 50% CEA), this would translate into an additional $2,000,000,000 in charges for these 3 years. It seems unreasonable to approve enhanced reimbursement for CAS at this time, especially since the large incremental costs would go to support CAS procedures that are inferior in most symptomatic patients and possibly unnecessary in most asymptomatic patients.

Association of Program Directors in Vascular Surgery (APDVS) survey of program selection, knowledge acquisition, and education provided as viewed by vascular trainees from two different training paradigms

2011-11-28

Methods of learning may differ between generations and even the level of training or the training paradigm, or both. To optimize education, it is important to optimize training designs, and the perspective of those being trained can aid in this quest. The Association of Program Directors in Vascular Surgery leadership sent a survey to all vascular surgical trainees (integrated [0/5], independent current and new graduates [5 + 2]) addressing various aspects of the educational experience. Of 412 surveys sent, 163 (∼40%) responded: 46 integrated, 96 fellows, and 21 graduates. The survey was completed by 52% of the integrated residents, 59% of the independent residents, and 20% of the graduates. When choosing a program for training, the integrated residents are most concerned with program atmosphere and the independent residents with total clinical volume. Concerns after training were thoracic and thoracoabdominal aneurysm procedures and business aspects: 40% to 50% integrated, and 60% fellows/graduates. Integrated trainees found periprocedural discussion the best feedback (79%), with 9% favoring written test review. Surgical training and vascular laboratory and venous training were judged “just right” by 87% and ∼71%, whereas business aspects needed more emphasis (65%-70%). Regarding the 80-hour workweek, 82% felt it prevented fatigue, and 24% thought it was detrimental to patient care. Independent program trainees also found periprocedural discussion the best feedback (71%), with 12% favoring written test review. Surgical training and vascular laboratory/venous training were “just right” by 87% and 60% to 70%, respectively, whereas business aspects needed more emphasis (∼65%-70%). Regarding the 80-hour workweek, 62% felt it was detrimental to patient care, and 42% felt it prevented fatigue. A supportive environment and adequate clinical volume will attract trainees to a program. For “an urgent need to know,” the integrated trainees are especially turning to online texts rather than traditional textbooks, which suggests an opportunity for a shift in educational focus. Point-of-care is the best time for education and feedback, suggesting a continued need for dedicated faculty. The business side of training is underserved and should be addressed.

Discussion

2011-11-28

Dr Jason Lee (Stanford, Calif). Dr Dalsing correctly points out that with the advent of new training paradigms in vascular surgery, we will have to study not only the reasons students and residents choose vascular surgery but also, when they are accepted into programs, what the issues are to keep them satisfied. I think that we have been successful in getting students interested in vascular surgery by encouraging participation in meetings such as the Society for Vascular Surgery and Peripheral Vascular Surgery Society, and we should foster this interest with constant re-evaluation.

Novel extra-anatomic intra-abdominal reconstruction for treatment of paravisceral aortic infection

Nitin Garg, Manju Kalra — 2011-12-16

Adequate treatment of native or prosthetic aortic infection requires extensive surgical debridement and establishing flow to the extremities using extra-anatomic or in situ reconstruction, each with its inherent limitations. Infection of the paravisceral aortic segment precludes an axillofemoral bypass as the sole treatment because of inability to provide visceral perfusion. In situ autograft or allograft reconstructions could be limited by conduit availability or significantly prolonged operative time, or both. Placement of an antibiotic-soaked prosthetic in a field with gross purulence carries a high risk of reinfection. We describe a technique for extra-anatomic, intra-abdominal reconstruction using an antibiotic-soaked prosthetic graft to avoid the infected paravisceral aortic bed and achieve antegrade lower extremity and visceral vessel perfusion.

Radiofrequency thermal wire is a useful adjunct to treat chronic central venous occlusions

Mark Iafrati, Stephen Maloney, Neil Halin — 2011-11-21

Conventional techniques for central venous recanalization are successful in crossing most lesions but still fail in many patients. We used a radiofrequency wire in these failed cases. We report three patients with complicated central venous occlusions in whom conventional catheter and guidewire techniques were not successful and who were successfully treated using the PowerWire Radiofrequency Guidewire (Baylis Medical Company Inc, Montreal, QC, Canada). Occlusions were traversed using the radiofrequency wire, followed by angioplasty and stenting. The average length recanalized was 8.2 ± 3.6 cm. One patient required repeat angioplasty at 4 months. All stents were patent at 12 to 15 months. The radiofrequency wire is valuable in the management of patients with refractory central venous occlusions.

Thrombolysis for deep venous thrombosis

Anthony J. Comerota — 2011-08-01

The key questions addressed in this summary are whether clot removal should be part of the preferred therapy for patients with acute deep venous thrombosis (DVT), and whether there is evidence that a strategy of thrombus removal offers better outcomes for patients than anticoagulation alone. Evidence is defined as an outward sign or something that furnishes proof. Evidence in medicine is not limited to direct, blinded comparisons of one form of treatment compared with another but rather the body of knowledge that provides insight to clinicians to offer patient care. Evidence-based medicine follows from information available to form the foundation for the use of a treatment for a specific disease. Reports of strategies of thrombus removal for acute DVT, especially in patients with iliofemoral DVT, consistently demonstrate improved outcomes relative to postthrombotic morbidity. This summary reviews the evidence supporting this strategy as the preferred initial management of patients with extensive proximal DVT.

Balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenoses of hemodialysis grafts after surgical thrombectomy

Sean P. Roddy — 2012-02-01

In 2010, CPT code 36147 was created and bundles the work of establishing single catheter access with the diagnostic contrast imaging of the dialysis circuit. In 2012, the introductory wording was updated to clarify reporting concerns voiced by the insurance industry and coding groups.

Arteriovenous Graft Placement in Predialysis Patients: A Potential Catheter-Sparing Strategy

R. Shingarev, I.D. Maya, J. Barker-Finkel — 2012-02-01

Arteriovenous grafts placed predialysis have primary failure rates and cumulative survival rates that are similar to grafts placed after starting dialysis therapy. The fistula first initiative (www.fistulafirst.org) strongly encourages dialysis access via arteriovenous fistulas. Some patients, however, have anatomy more suitable for a graft. In such cases the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) suggests grafts be placed three to six weeks prior to the need for dialysis therapy. It is difficult to predict the onset of time for the need of dialysis in patients not undergoing dialysis. Some surgeons postpone graft creation until after the initiation of hemodialysis reasoning graft placement prior to dialysis therapy may result in diminished time of patent access when the patient actually needs the access. However, postponing initiation of graft placement until after beginning dialysis therapy exposes the patient to the risk of catheter related bacteremia, central vein stenosis and decreased overall survival.

Association of Body Mass Index With Peripheral Arterial Disease in Older Adults: The Cardiovascular Health Study

J.H. Ix, M.L. Biggs, J.R. Kizer — 2012-02-01

Greater body mass index (BMI) is associated with peripheral arterial disease (PAD) in healthy older patients who never smoked. Novel and traditional cardiovascular disease risk factors are associated with PAD. One important cardiovascular risk factor previously not associated with PAD is BMI. Epidemiologic studies have either not demonstrated a relationship between PAD and BMI (Murabito JM. Am Heart J 2002;143:961-5, and Meijer WT et al. Arch Inter Med 2000;160:2934-8) or demonstrated an inverse association (Criqui MH. Circulation 2005;112:2703-7). Such studies have had cross sectional designs. In this study the authors hypothesize poor health and smoking status might simultaneously be associated with a lower BMI and greater PAD prevalence obscuring a positive association that might exist if adiposity itself leads to development of PAD. For this study the authors evaluated the association of BMI and PAD in adults age >65 years at baseline who are participating in The Cardiovascular Health Study (The Cardiovascular Health Study is a community based study of older adults with the goal to evaluate risk factors for development and progression of vascular disease). The authors also evaluated the association of BMI with subsequent incident clinical PAD events during follow up. They used self-reported recalled weight at age 50 to estimate mid-life BMI and evaluate its association with PAD prevalence at baseline. The analysis was repeated in a subset of participants who reported good health status and who had never smoked.

Asymptomatic Carotid Artery Stenosis and Cognitive Outcomes After Coronary Artery Bypass Grafting

I. Norkienë, R. Samalavièius, J. Ivaèius — 2012-02-01

Asymptomatic > than 50% carotid stenosis is a risk factor for cognitive decline following coronary artery bypass grafting (CABG). Patients anticipate CABG will improve their quality of life (Koch CG et al. Semin Cardiothorac Vasc Anesth 2008;12:203-17). Preservation and improvement of psycho- emotional well enhances quality of life. Neuropsychological disorders are being more frequently addressed in the care of the postoperative patient. Cerebrovascular disease and coronary artery disease potentionally put patients at risk for cognitive decline. In this paper the authors correlate asymptomatic carotid stenosis with cognitive decline following coronary artery bypass grafting (CABG). They sought to detect the incidence of cognitive decline following CABG, identify risk factors associated with such cognitive decline and to investigate a possible link between cognitive performance and asymptomatic carotid stenosis.

Dose-Related Effect of Statins in Venous Thrombosis Risk Reduction

D. Khemasuwan, Y.K. Chae, S. Gupta — 2012-02-01

Antiplatelet therapy and statin therapy are associated with reductions in the occurrence of venous thromboembolisim (VTE) with a dose related response of statins. Many of the same inflammatory mediators are elevated in patients with atherosclerosis and venous thrombosis (van Aken BE et al. Thromb Haemost 2000;83:536-9, and Sorensen HT. Lancet 2007;370:1773-9). Patients with a diagnosis of deep venous thrombosis and pulmonary embolism have higher risk of cardiovascular events over the next 20 years. In addition, patients with myocardial infarction or stroke have an increased risk of VTE within 3 months of diagnosis (Sorensen HT et al. J Thromb Haemost 2009;7:521-528) and patients with the metabolic syndrome and those with elevated levels of low density lipoprotein are also at increased risk of VTE (Ageno W et al. Circulation 2008;117:93-102). This emerging relationship between atherosclerosis and VTE with respect to biochemical etiologic factors led the authors to hypothesize statins and antiplatelet therapy could possibly have a role in preventing VTE in patients at high risk for atherosclerosis.

Late Follow-up of a Randomized Trial of Routine Duplex Imaging Before Varicose Vein Surgery

L. Blomgren, G. Johansson, L. Emanuelsson — 2012-02-01

Preoperative duplex imaging prior to varicose vein surgery reduces recurrence and need for reoperation over 7 years of post operative follow-up. Inadequate surgery secondary to in adequate preoperative investigation may contribute to recurrence following surgery for primary varicose veins (Blomgren L et al. Br J Surg 2005;92:688-94). The authors previously reported recurrence and reoperation 2 years after varicose vein surgery were lower with preoperative duplex examination (Blomgrin L et al. Br J Surg 2005;92:688-94). It has also been suggested groin surgery associated with saphenous vein open surgery induces recurrence through neovascularization. The aim of the current study was to evaluate the impact of preoperative duplex imaging after seven years with respect to recurrence of varicose veins, performance of reoperation and neovascularization as a source of recurrence.

Long-Term Results of Vascular Graft and Artery Preserving Treatment With Negative Pressure Wound Therapy in Szilagyi Grade III Infections Justify a Paradigm Shift

D. Mayer, B. Hasse, J. Koelliker — 2012-02-01

Szilagyi III infections are safely and effectively treated both short and long term with negative pressure wound therapy (NPWT). Wound infections with prosthetic graft or arterial involvement (Szilagyi grade III infections) can be associated with high morbidity and mortality (Kikta MJ et al. J Vasc Surg 1987;5:566-71). Traditional treatment for Szilagyi III infections is graft excision, radical debridement and secondary vascular reconstruction. NPWT was introduced in 1997 by Argenta and Morykwas (Morykwas MJ et al. Ann Plast Surg 1997;33:553-62). There have been small series of patients with vascular graft infections treated by NPWT without graft excision with apparently good short term results (Dosluoglu HH et al. J Vasc Surg 2010;51:1160-6).

Lower Extremity Vascular Injuries: Increased Mortality for Minorities and the Uninsured?

M. Crandall, D. Sharp, K. Brasel — 2012-02-01

There are mortality disparities associated with race and insurance status in patients with penetrating lower extremity vascular injury. Outcome disparities for Medicaid patients, people of color and the uninsured may be partially attributable to differences in baseline healthcare characteristics and/or hospital performance (Osborne NH et al. J Vasc Surg 2009;50:709-13). The author's considered that in trauma patients heterogeneity of injury, difficulties in injury measurement and a lack of standardized care may contribute to potential disparities in trauma outcomes, including vascular injury. Their hypothesis was that mortality rate disparities by socioeconomic status and race could be explained by injury heterogeneity. They therefore limited analysis of vascular injury to a group with homogenous injuries; those with lower extremity vascular injuries. They postulated disparities in outcome would be diminished or eliminated by such stratification. They used the National Trauma Data Bank version 7.0 of the American College of Surgeons to identify patients with lower extremity vascular injury. Univariate and multivariate analyses were performed using Stata software (version 11; StataCorp, LP, College Station, Tex). There were 4928 patients with lower extremity vascular injury identified. There were 2452 blunt injuries and 2452 penetrating injuries, with 24 cases where mechanism was unknown. Mortality was 7.6 % overall and did not differ by mechanism. Regression analysis, using mechanism as a covariate, revealed worse mortality for people of color (OR, 1.45; 95%CI, 1.03-2.02; P = .03) and worse mortality for the uninsured (OR, 1.62; 95%CI, 1.15-2.23; P = .006). When a separate analysis was performed stratified by mechanism there was no significant mortality disparity for blunt trauma; for people of color (OR, 1.28; 95%CI, 0.85-1.96; P = .23) or for the uninsured (OR, 1.33; 95% CI, 0.78-2.22; P = .29). There were however disparities for penetrating trauma, in people of color (OR, 1.18; 95%CI, 0.93-3.57; P = .08) and the uninsured (OR, 1.85; 95%CI, 1.19-2.94; P = .009).

The Predictive Ability of Preoperative B-Type Natriuretic Peptide in Vascular Patients for Major Adverse Cardiac Events: An Individual Patient Data Meta-Analysis

R.N. Rodseth, G.A.L. Buse, D. Bolliger — 2012-02-01

Preoperative natriuretic peptide levels are independent predictors of cardiovascular events in the first 30 days following vascular surgery and improve predictive performance of the revised cardiac risk index.

The War Against Error: A 15Year Experience of Completion Angioscopy Following Carotid Endarterectomy

2012-02-01

A policy of intra-operative transcranial Doppler (TCD) and completion angioscopy was previously associated with virtual abolition of intra-operative stroke (apparent upon recovery from anaesthesia) following carotid endarterectomy (CEA). The aims of this study were to determine whether the prevalence of technical error has diminished with experience and whether our monitoring/quality control policy was still associated with low rates of intra-operative stroke 20 years after its introduction.

Circulating Lipoprotein-associated Phospholipase A2 in High-grade Carotid Stenosis: A New Biomarker for Predicting Unstable Plaque

2012-02-01

To test plasma levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) in patients with high-grade carotid stenosis according to plaque histology. This cross-sectional single-centre study included patients with ≥70% North American Symptomatic Carotid Endarterectomy Trial (NASCET) carotid stenosis, who were treated surgically. Serum Lp-PLA2 and high-sensitivity C-reactive protein (hs-CRP) were determined on the day of surgery. Histopathological analysis classified carotid plaque as stable or unstable, according to AHA classification.

Is the Incidence of Abdominal Aortic Aneurysm Declining in the 21st Century? Mortality and Hospital Admissions for England & Wales and Scotland

A. Anjum, J.T. Powell — 2012-02-01

Between 1951 and 1995 there was a steady increase in age-standardised deaths from all aortic aneurysms in men, from 2 to 56 per 100,000 population in England & Wales, supporting an increase in incidence. More recently, evidence from Sweden and elsewhere suggests that now the incidence of abdominal aortic aneurysm (AAA) may be declining.

Assessment of the Accuracy of AortaScan for Detection of Abdominal Aortic Aneurysm (AAA)

A. Abbas, A. Smith, M. Cecelja, M. Waltham — 2012-02-01

AortaScan AMI 9700 is a portable 3D ultrasound device that automatically measures the maximum diameter of the abdominal aorta without the need for a trained sonographer. It is designed to rapidly diagnose or exclude an AAA and may have particular use in screening programs. Our objective was to determine its accuracy to detect AAA.

Endofibrosis and Kinking of the Iliac Arteries in Athletes: A Systematic Review

G. Peach, G. Schep, R. Palfreeman, J.D. Beard, M.M. Thompson, R.J. Hinchliffe — 2012-02-01

Kinking and endofibrosis of the iliac arteries are uncommon and poorly recognized conditions affecting young endurance athletes. Deformation or progressive stenosis of the iliac artery may reduce blood flow to the lower limb and adversely affect performance. The aim of this review was to examine the existing literature relating to these flow-limiting phenomena and identify a clear, unifying strategy for the assessment and management of affected patients.

Comparative Analysis of Endovascular and Open Popliteal Artery Aneurysm Repair: Midterm Results

2012-02-01

To compare patency of endovascular (ER) and open repair (OR) of popliteal artery aneurysms (PAA) and determine predictors of failed revascularization. The focus is midterm patency, because only early outcomes of ER are well known.

Outcome of Prosthetic Versus Vein Grafts for Below-Knee Bypass in Real World Practice

2012-02-01

Native venous conduit is preferred in below-knee vascular reconstructions. However, many argue that prosthetic grafts can perform well in crural bypass with adjunctive antithrombotic therapy. We therefore compared outcomes of below-knee bypass grafts using prosthetic conduit with adjunctive antithrombotic therapy to those using autologous vein.

Remote Iliac Artery Endarterectomy

Simon A. Papoyan, Derenik Maytesyan, Igor Abramov — 2012-02-01

Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relatively unknown surgical procedure. This prospective single-center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented.

Fate of the Contralateral Limb in Lower Extremity Amputation

2012-02-01

Lower extremity (LE) amputation is often performed in patients where both limbs are at risk due to vascular disease, yet the proportion of patients who progress to amputation on their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral limbs after initial amputation.

Observations of Chronic Cerebrospinal Venous Insufficiency (CCSVI) in Multiple Sclerosis Patients Using a Multimodality Imaging Protocol

2012-02-01

Chronic cerebrospinal venous insufficiency (CCSVI) has been implicated in the etiology of multiple sclerosis (MS), with truncular venous malformations leading to stenosis of the jugular (IJV) and azygous veins and result in insufficient drainage of the cerebrospinal venous circulation. Consistent with this theory is an increased mean transit time in MRI perfusion studies and histology showing hemosiderin deposits and pericapillary fibrin cuffs. This study prospectively evaluated patients with MS for the presence of CCSVI using duplex ultrasound (US), venography, and intravascular ultrasound (IVUS).

Prediction of Graft Patency and Mortality After Distal Revascularization and Interval Ligation for Hemodialysis Access-Related Hand Ischemia

2012-02-01

The goals for management of access-related hand ischemia (ARHI) are to reverse symptoms and salvage the access. Many procedures have been described, but the optimal treatment remains unresolved. In an effort to guide clinical decision making, this study was undertaken to document our outcomes for distal revascularization and interval ligation (DRIL) and identify predictors of bypass patency and patient mortality.

Complications of Endovascular Grafts in the Treatment of Pseudoaneurysms and Stenoses in AV Access

Jill Zink, Victor Erzurum, Robert Netzley, Dennis Wright — 2012-02-01

Endovascular stent grafts are used in the rescue of failing arteriovenous access. Reports claim the superiority of stent grafts and recommended these as a first-line treatment. We have observed a rise in the number of complications related to stent grafts in our patients. The following study was undertaken to assess the severity of these complications and their effect on access site maintenance.

Metabolic Syndrome: A Marker for Decreased Cumulative Patency Among Patients Undergoing Arteriovenous Fistula Placement

2012-02-01

The natural history of patients with metabolic syndrome (MetS) undergoing arteriovenous fistula placement is unknown. MetS has previously been found as a risk factor for poor outcomes for vascular surgery patients undergoing other interventions. The aim of this is study is to describe the outcomes of MetS patients undergoing primary arteriovenous fistula placement.

Prospective Neurocognitive Evaluation of Patients Undergoing Carotid Interventions

Elizabeth Hitchner, Kathleen Gillis, Lixian Sun, Allyson Rosen, Wei Zhou — 2012-02-01

During carotid interventions there is a risk of distal cerebral embolization. Here we prospectively investigate whether subclinical microembolization seen on postoperative MRI leads to cognitive deficits in a cohort of patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS).

The Prevalence of Carotid Artery Stenosis Varies Significantly By Race

2012-02-01

Certain races are known to be at increased risk for stroke, and the prevalence of carotid artery stenosis (CAS) is thought to vary by race. The goal of this study was to investigate the prevalence of CAS by race via analysis of a large population of patients who underwent vascular screening examinations.

Increased Hospital Use of Carotid Artery Stenting (CAS) Over Carotid Endarterectomy (CEA) is Associated With Inferior Outcomes in Asymptomatic Patients

2012-02-01

CAS has been shown to have higher perioperative stroke and death (PSD) rates than CEA in symptomatic, but less convincingly in asymptomatic patients. Limited CAS experience has been blamed for worse outcomes. We sought to compare the PSD rate of CAS vs CEA in an administrative database to determine if CAS usage variation is linked to PSD in asymptomatic patients at the hospital level.

TEVAR Using the Redesigned TAG Device (CTAG) For Traumatic Aortic Transection: A Nonrandomized Multicenter Trial

2012-02-01

To evaluate the safety and efficacy of the CTAG device for the endovascular repair of traumatic aortic transections. A prospective, nonrandomized, multicenter trial was conducted at 21 sites. Primary study end points included 30-day all-cause mortality and major adverse events. The efficacy end point was freedom from a major device event (MDE) requiring reintervention through 1-month follow-up.

Elevated Incidence of Spinal Cord Ischemia among Patients Undergoing TEVAR for Type B Aortic Dissections

2012-02-01

Spinal cord ischemia (SCI) is a dreaded complication of thoracic endovascular aortic repair (TEVAR) and has been reported to have lower rates in dissection patients when compared to other aortic pathologies. Techniques to prevent SCI are inconsistently applied, potentially due to the unclear risk factors, and are often not used in dissection patients due to the low reported incidence of SCI in those patients. We sought to assess our incidence of SCI among patients undergoing TEVAR for both acute and chronic type B aortic dissections and the potential implication of spinal drainage.

Aortic Remodeling Following TEVAR in Acute and Chronic Type B Dissection

2012-02-01

To determine the changes in aortic luminal diameter for patients with acute and chronic aortic dissection. Patients treated with TEVAR for type B aortic dissection (AD) were identified from a prospectively maintained registry. Health systems charts, medical correspondence, and computed tomography (CT) imaging were reviewed. Measurements for true lumen (TL) and false lumen diameters were recorded at the first transverse section directly inferior to the aortic arch. Maximum diameter (MD) was recorded at the point of maximal dilation, regardless of position. Data were analyzed for up to 2 years after endovascular intervention.

Anatomic Distribution of Stroke and Its Relationship to Perioperative Mortality and Neurologic Outcome Following TEVAR

2012-02-01

To assess the anatomic distribution of stroke after TEVAR and its relationship to perioperative mortality and neurologic outcome. A retrospective review was performed for patients undergoing TEVAR between 2001 and 2010. Aortic arch hybrid and abdominal debranching cases were excluded. Demographics, operative variables, and neurologic complications were examined. Stroke was defined as any new focal or global neurologic deficit with radiographic confirmation of cerebral infarction.

Benchmark Renal Outcome Measures of Open Repair of Complex Abdominal Aortic Aneurysms for Comparison with Fenestrated Endografts

2012-02-01

Renal outcomes after open repair of complex abdominal aortic aneurysms (cAAA) have been poorly described. This study provides a detailed, long-term analysis of clinical and anatomic renal outcome measures in a cohort of patients treated by open repair of cAAAs.

Staple-2: The Pivotal Study of the Aptus Endovascular AAA Repair System—24-Months Results

Manish Mehta, Ronald M. Fairman, David H. Deaton — 2012-02-01

Aptus is the first endograft with EndoStaples for proximal fixation. This study evaluated standard EVAR safety and efficacy end points. A prospective single-arm IDE study was performed. The Aptus System includes a modular endograft and stapling system. MAEs were defined as death, MI, stroke, renal failure, respiratory failure, or paralysis at 30 days. Composite success was defined as delivery success and absence of type I/III endoleak, migration >10 mm, rupture, and open conversion at 1 year.

Natural History of Saccular Aortic Aneurysms

2012-02-01

Repair of saccular aortic aneurysms (SAA) is frequently recommended based on a perceived predisposition to rupture, despite little evidence that these aneurysms have a more malignant natural history than fusiform aortic aneurysms.

Contemporary Outcomes of Endovascular Interventions for Arterial Acute Limb Ischemia (ALI)

2012-02-01

Thrombolysis for arterial acute limb ischemia (ALI) has become first-line therapy based on studies published more than 2 decades ago primarily using urokinase. The purpose of this study was to assess outcomes of patients treated for ALI using contemporary lytic agents and endovascular techniques.

Clinical Significance of the Clopidogrel-Proton Pump Inhibitor Interaction After Peripheral Endovascular Intervention

2012-02-01

The impact of proton pump inhibitor (PPI) administration on the antiplatelet effect of clopidogrel remains controversial. Studies suggest that mechanistic interactions between these medications may lead to higher rates of adverse cardiac events after myocardial infarction or coronary intervention. The objective of this study is to evaluate the effects of concurrent PPI and clopidogrel administration on outcomes after peripheral endovascular interventions.

Statin Therapy Is Associated With Improved Clinical Outcomes in Patients With Symptomatic Peripheral Arterial Disease Undergoing Endovascular Intervention

2012-02-01

Statin therapy has proven clinical benefits in patients undergoing endovascular interventions for cerebral, abdominal, and renal artery disease, and critical limb ischemia (CLI). The purpose of this study is to determine the effects of statin therapy on all patients undergoing peripheral intervention for symptomatic peripheral artery disease (PAD).

Regarding “Industry working with physicians through professional medical associations”

Richard P. Cambria, Clement Darling, Rebecca M. Maron — 2012-02-01

We read with interest the excellent supplement on industry relations. Dalsing appropriately raises concerns about how professional medical associations, such as the Society for Vascular Surgery (SVS), balance the benefits and risks of working with industry to provide member benefits. He suggests that 30% to 50% or more of most professional medical associations' operating budgets are supported by industry funding.

Correction

2012-02-01

In the January 2011 supplement of the Journal of Vascular Surgery, the article by Drs Brown and Rzucidlo (Brown KR, Rzucidlo E. Acute and chronic radiation injury. J Vasc Surg 2011;53(1 Suppl):15S-21S) listed an error in the Conclusions section of the article on page 20S. The word “stochastic” should read “deterministic” in the following sentence:

Correction

2012-02-01

In the January 2012 issue of the Journal of Vascular Surgery, the article by Drs Collins and Dietzek (Collins N, Dietzek A. Contiguous bilateral head and neck paragangliomas in a carrier of the SDHB germline mutation. J Vasc Surg 2012;55:216-9) had a couple published errors. This article should not have been listed as having been presented at the Thirty-eighth Annual Meeting of the New England Society for Vascular Surgery, and the correct corresponding author and address for reprint requests is as follows:

Editorial Board

2012-02-01

Information for authors

Anton N. Sidawy, Bruce A. Perler — 2012-02-01

Complete information for authors and editorial policies are available in the January and July issues, at our Web site www.jvascsurg.org, or at our Editorial Manager Web site at jvs.editorialmanager.com. An abbreviated checklist for manuscript submission follows. Manuscripts that are accepted for publication become the property of the Journal of Vascular Surgery®, which is copyrighted by the Society for Vascular Surgery®. They may not be published or reproduced in whole or in part without the written permission of the author(s) and the Journal.

Information for Readers

2012-02-01

Communications regarding original articles and editorial management should be addressed to Anton N. Sidawy, MD, and Bruce A. Perler, MD, Editors, Journal of Vascular Surgery, 633 N. St. Clair, 22nd Floor, Chicago, IL 60611; telephone: 312-334-2317; fax: 312-334-2320; e-mail: JVASCSURG@vascularsociety.org. Information for authors appears in the January and July issues, at www.jvascsurg.org, and at jvs.editorialmanager.com. Authors should consult this document before submitting manuscripts to this Journal. Address business communications to Journal Publisher, Elsevier Inc, 360 Park Avenue South, New York, NY 10010-1710. For Events of Interest, contact Andrew O'Brien, Journal Manager, at a.obrien@elsevier.com. Visit our Web site at www.jvascsurg.org.

Events of Interest

2012-02-01

News items of interest to the vascular surgeon must be received at least 8 weeks before the desired month of publication. Announcements published at no charge include those received from a sponsoring society of this Journal, those courses and conferences sponsored by state, regional, national, or international vascular surgical organizations, and universitysponsored continuing medical education courses. All other news items selected for publication carry a charge of $60.00 US for each insertion, and the fee must accompany the request to publish. Send announcements and payment, payable to this Journal, to Issue Management, Elsevier Inc., 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA, 19103.