European Journal of Vascular & Endovascular Surgery

Editorial Board

2010-03-01

In Memoriam Professor Dr. André Nevelsteen

BSVS (Belgian Society for Vascular Surgery), R. Verhelst, P. Peeters — 2010-02-15

André Nevelsteen departed this life on 9 December last, having bravely fought against a relentless disease. André Nevelsteen was born in Geel on 8 August 1951. He completed his medical studies at the Catholic University of Leuven with high distinction in 1975 and his training in general surgery in 1980. He then specialised in vascular surgery, during which he spent time in Professor Crawford's department in Houston. After this, he obtained the grade of Clinical Head of Vascular Surgery in 1992 and Chief of Vascular Surgery in 1999.

Cervical Access for Filter-protected Carotid Artery Stenting: A Useful Tool to Reduce Cerebral Embolisation

G. Palombo, N. Stella, V. Faraglia, L. Rizzo, C. Fantozzi, A. Bozzao, M. Taurino — 2009-11-30

Abstract: Background: Filter-protected transcervical carotid artery stenting (CAS) has been suggested to reduce the intraoperative cerebral embolisation observed during transfemoral CAS. We therefore evaluated clinical outcome and incidence of ischaemic lesions at diffusion-weighted magnetic resonance imaging (DW-MRI) after transcervical and transfemoral CAS.Methods: From March 2007 to May 2009, we performed filter-protected CAS in 135 patients with symptomatic (30%) or asymptomatic (70%) carotid stenosis above 70% and below 95%. In 44 patients with risky femoral access or unfavourable aortic arch anatomy, access to common carotid artery was achieved by a small cervical incision. In another 91 procedures we used a classic percutaneous femoral access. Preoperative and postoperative DW-MRI scans were obtained after 111 procedures (82%) – 35 transcervical and 76 transfemoral.Results: The incidence of clinical events (transient ischaemic attack (TIA) and stroke) was 2.3% after transcervical CAS and 19.8% after transfemoral CAS (P<0.01), without any deaths. DW-MRI disclosed new ischaemic lesions in five patients (5/35, 14.3%) after transcervical CAS and in 28 patients (28/76, 36.8%) after transfemoral CAS (P=0.015). All ischaemic lesions depicted after transcervical procedures were ipsilateral to the treated artery.Conclusions: Transcervical filter-protected CAS, compared with classic percutaneous procedures, seems to reduce clinical events and DW-MRI ischaemic damage and may be useful in selected patients.

Beneficial Changes of Serum Calcification Markers and Contralateral Carotid Plaques Echogenicity after Combined Carotid Artery Stenting Plus Intensive Lipid-lowering Therapy in Patients with Bilateral Carotid Stenosis

2009-12-09

Abstract: Objectives/design: In symptomatic patients treated with ipsilateral carotid artery stenting (CAS) plus intensive lipid lowering, we assessed the changes of osteopontin (OPN), osteoprotegerin (OPG) and the Gray-Scale Median (GSM) score contralateral to symptomatic carotid stenosis.Materials/methods: Forty-six symptomatic patients (group A) with significant carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial (NASCET): >70%) underwent ipsilateral CAS. Those patients had simultaneously contralateral low-grade carotid stenosis (NASCET: 30–69%). Group B included 67 symptomatic patients with low-grade bilateral carotid stenosis (NASCET: 30–69%), but without indications for revascularisation. All patients were treated with atorvastatin (10–80mg) to target low-density lipoprotein (LDL)<100mgdl−1. Blood samples and plaques' GSM score contralateral to brain infarct were assayed at baseline and after 6 months.Results: At baseline, there were no significant differences between groups (p>0.05). Six-month atorvastatin treatment equivalently improved lipid profile in both groups (p<0.05). The parameters hsCRP, OPN and OPG were significantly down-regulated within both groups, but to a greater extent in group A (p<0.05). Besides this, contralateral GSM score was significantly improved from baseline in both groups (p<0.01), but that increment was more pronounced in group A (vs. group B; p=0.041). These changes were inversely correlated with changes in OPN (p=0.014), OPG (p=0.011) and LDL (p=0.041).Conclusion: Ipsilateral CAS plus intensive lipid-lowering therapy was associated with enhanced contralateral carotid plaque stability and attenuated inflammatory burden and calcification inhibitors to a greater extent than atorvastatin therapy alone in patients with bilateral carotid stenosis.

Natural History of Thoraco-abdominal Aneurysm in High-Risk Patients

P.A. Hansen, J.M.J. Richards, A.L. Tambyraja, L.R. Khan, R.T.A. Chalmers — 2010-01-13

Abstract: Introduction: There is considerable interest in the role of novel endovascular techniques for the treatment of patients with complex aneurysms who are unsuitable for standard interventions. Knowledge of the natural history of these lesions, as well as other co-morbidities, is required in order that these techniques may be applied correctly in this high-risk group.Method: This study reviews the outcome of patients deemed to be unfit for surgery following assessment under the Scottish National Thoraco-abdominal aneurysm service (TAAA) service (2002–2008).Results: Of 216 patients assessed, 89 (41%) patients were considered to be unfit for intervention. The median (interquartile range, IQR) age of patients was 75 (70–80) years and there were 39 men (44%). Median (IQR) aneurysm size was 6 (5.6–7.0) cm. The median (IQR) follow-up time was 12 (7–26) months. There were 49 (55%) deaths during the follow-up period of which 23 (47%) cases were due to ruptured TAAA and 26 (53%) were not aneurysm-related. Comparing patients with aneurysms <6 cm (33 patients) with those aneurysms ≥6 cm (56 patients) there was no difference in aneurysm-related death (p = 0.32) or all-cause mortality (p = 0.147).Conclusion: Aneurysm-related mortality amongst patients unsuitable for open TAAA surgery is considerable and evolving endovascular techniques may permit intervention in selected patients. However any intervention can only be justified if the patient's life expectancy is sufficient to allow benefit to accrue.

Comments regarding ‘Natural History of Thoraco-abdominal Aneurysm in High-Risk Patients’

G. Melissano, R. Chiesa — 2010-01-22

In the present issue of the European Journal of Vascular and Endovascular Surgery, Hansen et al. report the outcome of patients with Thoracoabdominal Aortic Aneurysms (TAAA) assessed by the Scottish National TAAA Service and left untreated because judged unfit for surgery.

Aorto-oesophageal and Aortobronchial Fistulae Following Thoracic Endovascular Aortic Repair: A National Survey

R. Chiesa, G. Melissano, E.M. Marone, M.M. Marrocco-Trischitta, A. Kahlberg — 2010-01-22

Abstract: Objective: We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results.Methods: We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme.Results: Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 ± 12.5 months, overall survival was 16% (3/19).Conclusions: The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option.

Diameter of the Infrarenal Aorta as a Risk Factor for Abdominal Aortic Aneurysm: The Tromsø Study, 1994–2001

S. Solberg, S.H. Forsdahl, K. Singh, B.K. Jacobsen — 2009-11-27

Abstract: Objectives: We aim to study whether the diameter of the non-aneurysmatic infrarenal aorta influences the risk for abdominal aortic aneurysm (AAA) and whether the larger diameter in men can explain the male predominance in AAA.Design: This is a population-based follow-up study.Materials and methods: In 4265 men and women with a normal-sized aorta in 1994-1995, 116 incident cases of AAA were diagnosed 7 years later. The risk of an incident AAA was analysed in a multiple logistic regression model according to baseline maximal infrarenal aortic diameter, adjusted for known risk factors.Results: Compared with subjects with aortic diameter in the 21-23 mm bracket, men and women with a diameter <18mm and ≥27mm had an adjusted odds ratio (OR) of 0.30 (95% confidence interval (CI): 0.10–0.88) and 4.22 (95% CI: 1.94–9.19), respectively, for an incident AAA. When adjusted for age and baseline aortic diameter, male sex was not statistically significantly associated with the incidence of AAA (OR=1.45, 95% CI: 0.93–2.30, P=0.10).Conclusions: Increased baseline diameter of the infrarenal aorta was a highly significant, strong and independent risk factor for developing an AAA. The larger aortic diameter in men than in women may be the most important explanation for the higher AAA risk in men.

Endovascular Aneurysm Repair with Preservation of the Internal Iliac Artery Using the Iliac Branch Graft Device

2009-12-04

Abstract: Objectives: Aortoiliac aneurysms comprise up to 43% of the specialist endovascular caseload. In such cases endovascular aneurysm repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing endovascular solution.Design: Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review.Results: Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85–100%. Median operating times were 101–290min and median contrast dose was 58–208g, with no aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed endovascularly. Re-occlusion occurred in 24/196 patients.Conclusion: IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.

High Levels of 18F-FDG Uptake in Aortic Aneurysm Wall are Associated with High Wall Stress

2009-11-19

Abstract: Background: Functional imaging using positron emission tomography (PET) showed increased metabolic activities in the aneurysm wall prior to rupture, whereas separate studies using finite element analysis techniques found the presence of high wall stresses in aneurysms that subsequently ruptured. This case series aimed to evaluate the association between wall stress and levels of metabolic activities in aneurysms of the descending thoracic and abdominal aorta.Methods: Five patients with aneurysms in the descending thoracic aorta or abdominal aorta were examined using positron emission tomography–computed tomography (PET-CT). Patient-specific models of the aortic aneurysms were reconstructed from CT scans, and wall tensile stresses at peak blood pressure were calculated using the finite element method. Predicted wall stresses were qualitatively compared with measured levels of 18F-fluoro-2-deoxy-glucose (18F-FDG) uptakes in the aneurysm wall.Results: The distribution of wall stress in the aneurysm wall was highly non-uniform depending on the individual geometry. Predicted high wall stress regions co-localised with areas of positive 18F-FDG uptake in all five patients examined. In the two ruptured cases, the locations of rupture corresponded well with regions of elevated metabolic activity and high wall stress.Conclusions: These preliminary observations point to a potential link between high wall stress and accelerated metabolism in aortic aneurysm wall and warrant further large population-based studies.

Peak Wall Stress Does Not Necessarily Predict the Location of Rupture in Abdominal Aortic Aneurysms

2009-12-14

Abstract: Using finite element analysis, we evaluated if the site of an aortic bleb, known to be prone to rupture, coincides with the location of peak wall stress (PWS) in a patient-specific abdominal aortic aneurysm (AAA) model.Report: PWS was not located at the bleb site, even when stress values were estimated for different bleb wall thicknesses (0.5–2.0 mm) while the rest of the AAA wall was considered constant (2 mm).Discussion: The sites of PWS in AAAs should not always be considered as the sites most prone to rupture since other factors, such as wall strength, may play a role in rupture-risk prediction, depicting the need for further investigation of these parameters.

Hepatorenal Bypass Allowing Fenestrated Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysm: A Case Report

2009-11-30

Abstract: A 61-year-old man presented with a 66-mm juxtarenal aortic aneurysm. He was unfit for open repair. The anatomical proximity of his right renal artery (RRA) and his superior mesenteric artery (SMA) precluded fabrication of an endograft allowing perfusion of both vessels. He underwent a hepato-renal bypass to his RRA and subsequent fenestrated endovascular aneurysm repair (EVAR) using an endoprosthesis with fenestrations for the SMA and the left renal artery (LRA), and a scallop for the coeliac trunk. Follow-up imaging showed all visceral vessels to be perfused. The use of this limited hybrid approach allows endovascular treatment of aneurysms that are initially unsuitable for such an approach.

Endovascular Treatment of Profunda Femoris Artery Obstructive Disease: Nonsense or Useful Tool in Selected Cases?

2009-11-11

Abstract: Background: To evaluate the therapeutic value of endovascular techniques for the treatment of profunda femoris artery obstructive disease (PFAOD) in critical limb ischaemia (CLI) patients, with technically demanding open profunda repair.Design: Retrospective study of prospectively collected data of 15 consecutive CLI patients with technically demanding surgical treatment of PFAOD, that were treated by endovascular means in two European Centers of Vascular Surgery.Materials: All patients had critical limb ischaemia with a history of at least two previous vascular reconstructions in the ipsilateral groin and severe co-morbid conditions. All patients had good common femoral artery flow, long occlusion of the superficial femoral and popliteal arteries and impairment of crural arteries.Methods: Twelve patients underwent balloon angioplasty alone and, in the other three cases, an additional stent placement was necessary, due to flow-limiting dissection. The follow-up (mean 29.2±10 months) included a surveillance protocol with the best medical treatment and duplex scanning at 1, 3, 6, 12 months and yearly thereafter.Results: The endovascular approach was technically successful in all cases and the procedure-related morbidity and mortality rates were 0% for the entire follow-up period. The 3-year primary and secondary patency rates of the treated segment were 80% and 86.7%, respectively. The limb salvage rate was 93.3%.Conclusions: The outcome of our series underscores the therapeutic value of balloon angioplasty in cases of severe PFAOD, as bailout treatment in critical limb ischaemia patients with technically demanding open profunda repair. This procedure can be repeated easily if significant restenosis occurs and provides a useful tool in selected cases.

Comments regarding ‘Endovascular Treatment of Profunda Femoris Artery Obstructive Disease: Nonsense or Useful Tool in Selected Cases?’

C.J. Zeebregts, I.F.J. Tielliu — 2010-01-18

After the introduction of a surgical profundoplasty to resolve stenotic disease primarily located at the origin of the profunda femoris artery (PFA) in 1972 by Martin et al. not much has happened in the field of profunda revascularisation in more than 35 years of time. The technique is still appreciated, especially in patients with severe distal femoropopliteal disease in whom there are no distal landing zones for bypass surgery depending entirely on collateral flow. Although in the early 1980s, several reports appeared describing good technical and early results with percutaneous angioplasty (PTA) of the PFA, surgical reconstruction has remained the gold standard ever since.

PAD as a Risk Factor for Mortality Among Patients with Elevated ABI – A Clinical Study

V. Suominen, I. Uurto, J. Saarinen, M. Venermo, J. Salenius — 2010-01-20

Abstract: Objective: This study aims to evaluate mortality across ankle–brachial index (ABI) values and to assess the association between elevated ABI, peripheral arterial disease (PAD) and mortality.Design: This is a retrospective clinical study.Material and methods: A total of 2159 patients referred with a suspicion of PAD had their ABI and toe brachial index (TBI) measured by photoplethysmography. ABI ≥1.3 was considered falsely elevated while TBI <0.60 was the diagnostic criterion for PAD among the subjects. The cohort was followed up for total and cardiovascular mortality until 30 June 2008, by record linkage with the National Causes-of-Death Register.Results: The average follow-up time was 39 months. A total of 576 (26.7%) patients died during the follow-up. Mortality was highest in the elevated ABI group (35.7% for elevated ABI; 30.1% for low ABI and 16.0% for normal ABI, p < 0.001). There was a greater than twofold risk of total, and an increased but statistically non-significant risk of, cardiovascular mortality among patients with elevated ABI. Similar risk ratios were noted for the low ABI (≤0.9) group. More pronounced associations were observed at both ends of the scale when ABI was divided into sub-categories. The overall survival was significantly worse for the elevated ABI group than for both the normal and the low-ABI group (p < 0.01 and p = 0.013, respectively). PAD was found to be independently associated with both total and cardiovascular mortality among those with elevated ABI (odds ratio (OR): 2.21; 95% confidence interval (CI): 1.01–4.85 and OR: 4.90; 95% CI: 1.50–16.04, respectively).Conclusions: The association between elevated ABI and poor survival is similar to that of low ABI. PAD appears to be an independent risk factor for mortality among patients with elevated ABI.

Functional Outcome of Hypogastric Revascularisation for Prevention of Buttock Claudication in Patients with Peripheral Artery Occlusive Disease

A. Paumier, P. Abraham, G. Mahé, E. Maugin, B. Enon, G. Leftheriotis, J. Picquet — 2009-11-12

Abstract: We have defined proximal lower limb ischaemia as a decrease in Exercise-transcutaneous oxygen pressure (TcPO2) lower than minus 15mmHg at the buttock level in patients with peripheral artery occlusive disease. The purpose of this study was to objectively evaluate the benefits of direct versus indirect revascularisation of internal iliac arteries (IIAs) for prevention of buttock claudication in this population.We retrospectively reviewed the charts of proximal ischaemia patients who underwent revascularisation and both preoperative and postoperative stress TcPO2 testing. Revascularisation procedures were classified as either direct revascularisation, including percutaneous transluminal angioplasty and internal iliac artery bypass, resulting in a direct inflow in a patent IIA (group 1) or indirect revascularisation, including aortobifemoral bypass and recanalisation of the femoral junction on the ischaemic side, resulting in indirect inflow from collateral arteries in the hypogastric territory (group 2). Patency was checked 3 months after revascularisation in all cases.Treadmill exercise stress tests were performed before and after revascularisation using the same protocol designed to assess pain, determine maximum walking distance (MWD) and measure TcPO2 during exercise. In addition, ankle–brachial indices (ABIs) were calculated.Between May 2001 and March 2008, a total of 93 patients with objectively documented proximal ischaemia underwent 145 proximal revascularisation procedures using conventional open techniques in 109 cases and endovascular techniques in 36. Direct revascularisation was performed on 50 limbs (35%) (group 1) and indirect revascularisation on 95 limbs (65%) (group 2). The mean interval between revascularisation and stress testing was 60±74 days preoperatively and 149±142 days postoperatively.No postoperative thrombosis was observed. Buttock claudication following revascularisation was more common in group 2 (p<0.001). No difference was observed between the two groups with regard to improvement in MWD (365 / 294 m) and ABI (0.20/0.22). Disappearance of proximal ischaemia was more common after direct revascularisation (p<0.01). The extent of lesions graded according to the TASC II classification appeared not to be predictive of improvement in assessment criteria following revascularisation. Conversely, patency of the superficial femoral artery was correlated with improvement (p<0.01).This study indicates that direct revascularisation, if feasible, provides the best functional outcome for prevention of buttock claudication.

VEGF: A Surrogate Marker for Peripheral Vascular Disease

2009-11-05

Abstract: This study aims to evaluate the value of VEGF as a surrogate marker for peripheral vascular disease (PVD). Prior to treatment, serum VEGF levels were evaluated by enzyme-linked immunosorbent assay (ELISA) in 293 PVD patients. Risk factors and clinical parameters of PVD were documented. Twenty-six age-matched healthy volunteers served as controls. Serum VEGF values strongly correlated with Fontaine stages (p<0.006, stage IV vs. controls). High VEGF values prior to treatment were associated with poor outcome. Serum VEGF appears to indicate the severity of PVD and might serve as a surrogate indicator of disease severity.

Surgical Techniques to Improve Cannulation of Hemodialysis Vascular Access

2010-01-11

Abstract: Objective: Successful access cannulation is of utmost importance for adequate hemodialysis treatment. Upper arm fistulae, obesity and deep or tortuous veins may impair needling and can cause significant complications and inconvenience for the patient. In the ultimate case, cannulation problems lead to temporary central vein catheter use for dialysis or even to irreversible access loss. Surgical access revision may enhance successful cannulation.Methods: A systematic literature review of all publications related to hemodialysis vascular access, cannulation complications and treatment was performed.Results: A total of 384 publications were identified, of which only 17 were related to treatment of cannulation complications in large patient populations. The clinical success rate of surgical intervention with vein elevation or transposition ranges from 85% to 91%. The 1-year primary and secondary patencies are 60% and 71%, respectively. Lipectomy results in an initial success rate of 100% with a primary and secondary patency of 71% and 98%, respectively, after 1 year of follow-up.Conclusion: Surgical revision to improve hemodialysis vascular access cannulation has a high clinical success rate with good long-term patency.

Preoperative Mapping for Haemodialysis Access Surgery with CO2 Venography of the Upper Limb

S. Heye, I. Fourneau, G. Maleux, K. Claes, D. Kuypers, R. Oyen — 2010-01-18

Abstract: Objective: This study aims to evaluate the impact of CO2 venography on the planning and outcome of native arteriovenous fistula (AVF) creation.Methods: Records of patients who underwent CO2 venography prior to access surgery between January 2000 and December 2008 were reviewed. CO2 venography was performed selectively in chronic kidney disease (CKD) in stage IV–V patients without suitable veins on clinical examination. Findings at surgery were compared to CO2 venography images. Patency of AVFs was analysed by the Kaplan–Meier method. Differences in outcome of maturation were compared using a χ2 test.Results: A total of 209 CO2 venograms were obtained in 116 patients. In 89 patients (77%), 101 AVFs (21 forearm AVF (21%) and 80 elbow AVF (79%) were created. Surgical findings corresponded with CO2 venography findings in 90% of patients. In 10 cases (10%), access was created at the elbow despite a patent forearm cephalic vein on CO2 venography (n = 2) or access was attempted with a vein which was thought to be unsuitable on CO2 venography (n = 8). Maturation rate of the latter was 50% (4/8) vs. 88% (80/91) for AVFs created with veins considered usable (P = 0.004). The overall maturation rate was 84% with 1-year primary, assisted primary and secondary patency rates of 63%, 70% and 71%, respectively.Conclusion: CO2 venography is a useful tool for venous mapping prior to vascular access surgery, resulting in an overall maturation rate of 84% and good patency rates.

Combined Simultaneous Basilic and Brachial Vein Transposition. A New Technique to Create an Autologous Vascular Access

T.I. Kostas, C.V. Ioannou, E. Georgakarakos, A.N. Katsamouris — 2009-12-18

Abstract: In this report, we present a technique to extend the function of an antecubital arteriovenous fistula in which both the basilic and the brachial veins were simultaneously transposed to create an autologous graft in the arm. This procedure may particularly be applicable for patients in whom, although a brachio-cephalic fistula, anastomosing the brachial artery and the perforating antecubital vein, has been previously performed and has remained patent arterialising the deep arm veins, the cephalic vein has failed to mature or has been thrombosed after multiple punctures. Our preliminary experience in eight patients has shown satisfactory outcome.

Longterm Results After Surgical Thrombectomy and Simultaneous Stenting for Symptomatic Iliofemoral Venous Thrombosis

P. Hölper, D. Kotelis, N. Attigah, A. Hyhlik-Dürr, D. Böckler — 2010-01-11

Abstract: Objectives: To evaluate the longterm outcome of venous thrombectomy and simultaneous stenting in patients with acute, symptomatic iliofemoral deep venous thrombosis (DVT).Methods: Between January 1996 and December 2007, a total of 45 patients underwent venous thrombectomy at our institution. Thrombectomy results were classified by intraoperative phlebography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because no endovascular repair was performed.25 patients underwent a venous hybrid operation comprising balloon-catheter thrombectomy, thrombolysis and stenting of residual stensosis. Three TYPE 2 and 22 TYPE 3 lesions were diagnosed. Three patients died during follow-up from causes unrelated to their treatment. Three were lost to follow-up. Hence, 19 patients were examined. A retrospective, non comparative single-centre study was performed.Results: Median follow-up was 68 months (range 3–129). Primary and secondary patency rates were 74% (14/19) and 84% (16/19), respectively. Re-thrombosis occurred within seven days of operation in 26% (5/19). Procedure related mortality was zero. There was no case of late re-thrombosis. Four patients showed post-thrombotic sequelae (CEAP: C1, 2 or 3s). No leg ulcer developed in any patient.Conclusion: Venous thrombectomy with simultaneous stenting results in excellent longterm results in selected patients with symptomatic iliofemoral venous thrombosis.

Residual Venous Obstruction, alone and in Combination with D-Dimer, as a Risk Factor for Recurrence after Anticoagulation Withdrawal following a First Idiopathic Deep Vein Thrombosis in the Prolong Study

2009-12-25

Abstract: Objective: This study aims to assess the predictive value of residual venous obstruction (RVO) for recurrent venous thrombo-embolism (VTE) in a study using D-dimer to predict outcome.Design: This is a multicentre randomised open-label study.Methods: Patients with a first episode of idiopathic VTE were enrolled on the day of anticoagulation discontinuation when RVO was determined by compression ultrasonography in those with proximal deep vein thrombosis (DVT) of the lower limbs. D-dimer was measured after 1 month. Patients with normal D-dimer did not resume anticoagulation while patients with abnormal D-dimer were randomised to resume anticoagulation or not. The primary outcome measure was recurrent VTE over an 18-month follow-up.Results: A total of 490 DVT patients were analysed (after excluding 19 for different reasons and 118 for isolated pulmonary embolism (PE)). Recurrent DVT occurred in 19% (19/99) of patients with abnormal D-dimer who did not resume anticoagulation and 10% (31/310) in subjects with normal D-dimer (adjusted hazard ratio: 2.1; p = 0.02). Recurrences were similar in subjects either with (11%, 17/151) or without RVO (13%, 32/246). Recurrent DVT rates were also similar for normal D-dimer, with or without RVO, and for abnormal D-dimer, with or without RVO.Conclusions: Elevated D-dimer at 1 month after anticoagulation withdrawal is a risk factor for recurrence, while RVO at the time of anticoagulation withdrawal is not.

The Impact of Different Concentrations of Sodium Tetradecyl Sulphate and Initial Balloon Denudation on Endothelial Cell Loss and Tunica Media Injury in a Model of Foam Sclerotherapy

A. Ikponmwosa, C. Abbott, A. Graham, S. Homer-Vanniasinkam, M.J. Gough — 2010-01-18

Abstract: Introduction: Recanalisation rates (20–32%) 1–3 years after truncal vein foam sclerotherapy (FS) suggest thrombotic occlusion rather than irreversible vein wall injury. This study examines the injury inflicted by sodium tetradecyl sulphate (STD) foam before and after balloon endothelial denudation (BD).Methods: In 20 patients undergoing great saphenous vein (GSV) stripping 1.5 cm proximal GSV were harvested (controls). The next 1.5 cm were harvested after in situ BD (n = 10) or no denudation (n = 10). These test segments were filled with 1% or 3% STD foam (5 min), flushed and fixed in formalin. Percentage endothelial cell loss (ECL) and tunica media injury were determined (H&E staining) and collagen structure assessed (transmission electron microscopy, TEM).Results: Controls showed no injury. 1% and 3% STD foam caused 86.3% and 92.2% ECL (p < 0.001 versus controls; 1% versus 3%, p = 0.55). Endothelial cells persisted in all sections. BD increased ECL (1%: 96.9%, 3%: 98.1%, p = 0.01)Tunica media injury (smooth muscle vacuolation) was minimal (8.9% (1% STD) and 12% (3% STD) of its depth) and not enhanced by BD (1%: 8.7%, p = 0.93; 3%: 11.3%; p = 0.86). No collagen disruption occurred (TEM).Conclusions: Balloon denudation increased ECL but did not facilitate tunica media injury. Equivalent injury was inflicted by 1% and 3% STD.

Response to comments on “Separation of Components in Fenestrated and Branched Endovascular Grafting”

R.K. Greenberg, T.M. Mastracci, K. West — 2009-12-25

Multiple factors contribute to destabilization forces, but cross-sectional area reduction and angulation within the graft overwhelmingly constitute the major components of load, and thus device displacement forces. Devices are distorted in a downward direction unless otherwise opposed, so require enough strength to resist displacement, and the ability to deal with the potential for morphologic change. In truth, all endografts represent some combination of the two.

Comment on “Long-Term Results using Catheter-directed Thrombolysis in 103 Lower Limbs with Acute Iliofemoral Venous Thrombosis”

I. Weinberg — 2010-01-11

I have read with interest the article published by Baekgard et al. regarding a single center's experience with catheter directed thrombolysis of iliofemoral venous thrombosis. This article demonstrates potential benefits of thrombolysis in the treatment of deep vein thrombosis, especially in the prevention of late complications. However, some additional data would have been helpful. Anticoagulant treatment may affect recurrence rate and therefore, indirectly, local complication rate. Treatment duration is a matter of debate but probably should be tailored according to patient characteristics. It would therefore have aided to our understanding if Baekgaard and colleagues added the information regarding their patient's anticoagulation regimens and adherence. Furthermore, graded compression stockings may have yet another beneficial effect in preventing the post-phlebitic syndrome. Report of the use of such devices in the studied population could have added more to our understanding of the actual benefits of catheter directed thrombolysis in preventing late complications of deep vein thrombosis.

Response to comment on “Long-Term Results using Cateter-directed Thrombolysis in 103 Lower Limbs with Acute lliofemoral Venous Thrombosis”

N. Baekgaard — 2010-01-11

Thank you very much for your comments to our publication. We agree that several additional procedures could be important for our excellent results in this series, and among these the beneficial of using compression stockings and securing sufficient anticoagulation treatment. However, we doubt that these additional treatment modalities are the main course for the success of catheter-directed thrombolysis for deep venous thrombosis in our material. The fact that the immediate thrombus removal is almost 100 % is in our mind unrelated to the factors mentioned above. In the abstract we have prescribed compression stockings and anticoagulation using warfarin for at least 1 year, and indefinitely in patients with severe thrombophilia. Approximately one third of the patients are receiving long-life anticoagulation. The long term results most logically must be due to the early thrombus removal thereby saving patency and valve function in these patients with iliofemoral deep venous thrombosis. In our experience we seldom observe spontaneous thrombolysis in patients with iliofemoral deep venous thrombosis.

Selected Abstracts from the March issue of the Journal of Vascular Surgery

2010-03-01

Intraoperative Buttock Ischemia with Postoperative Necrosis following Infrainguinal Bypass Surgery

W. Al-Jundi, A. Durham-Hall, E. Oakley, J. Beard — 2009-12-21

Buttock necrosis is a rare presentation of severe pelvic ischaemia. It has been reported following open abdominal aortic repair and after internal iliac embolisation prior to endovascular treatment of aortic aneurysm. The internal iliac arteries are the major blood supply to the pelvis and buttocks. Collateral connections between the rectal and gluteal branches of the internal iliac artery and the deep femoral artery are well recognised. Iatrogenic interruption of this collateral circulation following rectal surgery resulting in limb ischaemia has been described. We present an exceptional case of buttock necrosis following infrainguinal bypass in a patient with bilateral internal iliac and left external iliac artery occlusions. The case is the first such reported to our knowledge.

Extracranial Internal Carotid Artery Mycotic Aneurysm: A Case Report

2010-01-11

Mycotic aneurysms of the extracranial carotid arteries (MCAs) are extremely rare. They usually appear as an enlarging pulsatile neck mass with no specific signs and symptoms, and they can lead to severe morbidity and mortality if left untreated. We report a case of a saccular thrombosed MCA in a 68-year-old man, presented as a non-pulsatile enlarging mass. The patient did not have any clinical signs of infection, and he was treated with resection of the MCA and synthetic patch reconstruction of the carotid bifurcation. Postoperative microbial cultures revealed Streptococcus parasanguinis. We review and discuss the literature regarding the clinical presentation, diagnosis and treatment options of MCAs.

Aneurysm of the Deep Circumflex Iliac Artery: A Rare Cause of Rectus Sheath Haematoma

K. Miyagi, M. Mulchandani, D.J.B. Marks, M. Mohamed — 2009-12-21

We describe the presentation and management of a case of rectus sheath haematoma secondary to spontaneous rupture of a deep circumflex iliac artery aneurysm. This was successfully treated with coil embolization. Such a case has never, to our knowledge, previously been reported.

Late Survival After Endovascular Repair of an Aortobronchial Fistula

L. Ribé, J. Río, J.L. Portero, L. Reparaz — 2010-01-11

We present an interesting case of a patient who underwent initial open repair of a descending thoracic aortic aneurysm in 1996, who subsequently had a pseudo-aneurysm that arose from his prosthetic graft, which was repaired with open surgery in 1998. He then developed a second pseudo-aneurysm with an aortobronchial fistula. This was successfully treated with an endovascular stent graft in 1999. The patient has survived 10years after this procedure.

Corrigendum to “Results of Surgical Treatment Compared with Ultrasound-Guided Foam Sclerotherapy in Patients with Varicose Veins: A Prospective Randomised Study” [European Journal of Vascular and Endovascular Surgery 38(2009)758–63]

M. Figueiredo, S. Araújo, N. Barros, F. Miranda — 2010-01-25

The authors regret that an error occurred in the final sentence of the Results section within the Abstract of their published paper. The correct sentence is as follows:

Forthcoming events

2010-03-01