European Journal of Vascular & Endovascular Surgery

Editorial Board

2012-06-01

Endovascular Aortic Aneurysm Repair – Still a Failed Experiment?

I. Nordon, M.M. Thompson, I.M. Loftus — 2012-04-09

Endovascular aneurysm repair [EVR] has been described as unethical, financially unviable and a ‘failed experiment’. Although the uptake of EVR has flourished with a robust evidence base, there remains concern regarding long-term viability, fed by the long-term outcome data from the EVAR-1 trial. The authors reiterated the early survival advantage following EVR compared to open surgery [OR] (adjusted odds ratio for EVR vs. OR, 0.39; 95% confidence interval [CI], 0.18 to 0.87; P = 0.02) but highlighted the 8-year follow-up data as demonstrating that EVR is associated with increased rates of graft-related complications, re-interventions and cost despite similar aneurysm-related mortality (adjusted hazard ratio, 0.92; 95% CI, 0.57 to 1.49; P = 0.73). These long-term results of EVAR-1 have been lauded by endovascular sceptics as a failure of the technology. Furthermore, additional subgroup analysis from EVAR-1 has described significant numbers of aortic ruptures with associated mortality. It would appear, from EVAR-1 trial data, that the catch up in aneurysm-related mortality in the EVR group is due to the development of endograft-related complications and rupture. It remains imperative that endovascular techniques should be robustly evaluated, but the question as to whether open surgery or endovascular repair offers the “best approach” is too simplistic, especially for patients deemed unfit for OR.

Is it Time to Nail the Lid on the Coffin of Open Abdominal Aortic Aneurysm Repair? Not so Sure!

J.-P. Becquemin, F. Schneider, J.-B. Ricco — 2012-04-16

Vascular clinical practice has changed dramatically during the last two decades and endovascular techniques prevail for the majority of arterial pathologies, including occlusive and aneurysmal disease. At present, not a single vascular surgeon considers that endovascular aneurysm repair (EVR) is a failed experiment. On the contrary as proven by national registries in Europe and USA, EVR is by and large the prevailing option for the treatment of aortic aneurysms (AAA). However, many surgeons will still choose open repair (OR) for young patients fit for surgery and also for those with unfavourable EVR anatomy. Are they right?

Association between Plaque Echogenicity and Embolic Material Captured in Filter during Protected Carotid Angioplasty and Stenting

2012-04-09

Abstract: Objectives/design: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors.Materials/methods: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I–V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep® liquid-based cytology (LBC) technique.Results: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15–4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02–5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28–326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho −0.716; p = 0.02).Conclusions: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

Asymptomatic Carotid Artery Stenosis: Identification of Subgroups with Different Underlying Plaque Characteristics

2012-04-16

Abstract: Objectives: Optimal surgical treatment of patients with asymptomatic carotid artery stenosis (ACAS) remains a matter of debate. Established definitions of ACAS include: (1) patients who never suffered from ipsilateral cerebrovascular events (group 1) or (2) patients who suffered from ipsilateral cerebrovascular events more than 6 months prior to revascularisation (group 2). Cerebrovascular symptoms are closely related to underlying carotid plaque composition and therefore we investigated potential plaque differences between these definition-based subgroups.Design: Cross-sectional analysis of a longitudinal prospective biobank study.Material and methods: Carotid atherosclerotic plaques from 264 asymptomatic patients were harvested during endarterectomy, and subjected to histopathological examination. Patients were divided into two groups: group 1: truly asymptomatic (n = 182), and group 2: patients with ipsilateral events more than 6 months before carotid endarterectomy (CEA) (n = 82).Results: Patients in group 1 had relatively more stable plaque characteristics as compared with patients in group 2, with a higher median plaque smooth muscle cell content (2.1 (0.0–18.7) vs. 1.6 (0.0–14.4); P = 0.036), a higher proportion of heavily calcified plaques (67.7% (123/182) vs. 48.8% (40/82); P = 0.005) and less frequently intraplaque haemorrhages (11.5% (21/182) vs. 30.5% (25/82); P = 0.001).Conclusion: Different plaque characteristics within subgroups of ACAS patients can be identified based on reported past ipsilateral events, which might result in adjusted future treatment strategies.

Delayed Carotid Surgery: What Are the Causes in the North West of England?

D. Purkayastha, S.W. Grant, J.V. Smyth, C.N. McCollum — 2012-04-16

Abstract: Introduction: Carotid endarterectomy (CEA) should be performed within two weeks of symptoms for patients with carotid stenosis >50%. Whether these standards are being achieved and causes of delay between symptoms and CEA were investigated.Design: An analysis of prospectively collected multi-centre data.Materials: Consecutive data for patients undergoing CEA between January-2006 and September-2010 were collected. Asymptomatic patients and those with no details on the timing of cerebral symptoms were excluded.Methods: ‘Delay’ from symptom to CEA was defined as more than two weeks and ‘prolonged-delay’ more than eight weeks. Univariable and multivariable analyses were used to identify factors associated with these delays.Results: Of 2147 patients with symptoms of cerebral ischaemia, 1522(70.9%) experienced ‘delay’ and 920(42.9%) experienced ‘prolonged delay’. Patients with ischaemic heart disease were more likely to experience ‘delay’ (OR = 1.56; 95% CI 1.11–2.19, p = 0.011), whereas patients with stroke (OR = 0.77; 95%CI 0.63–0.94, p = 0.011) and those treated at hospitals with a stroke-prevention clinic (OR = 0.57; 95%CI 0.46–0.71, p < 0.001) were less likely to experience ‘delay’. Patients treated after the publication of National Institute for Health and Clinical Excellence (NICE) guidelines were less likely to experience ‘prolonged delay’ (OR = 0.77; 95%CI 0.65–0.91, p = 0.003) but not ‘delay’.Conclusion: Few patients achieved CEA within two weeks of symptoms. Introducing stroke-prevention clinics with one-stop carotid imaging appears important.

Commentary on ‘Delayed Carotid Surgery: What are the Causes in the North West of England?’

D.C. Mitchell — 2012-04-16

Providing rapid access to surgical intervention or carotid stenting following TIA and minor stroke is an essential step in reducing stroke and death rates in patients with significant carotid stenosis. This has been recognised by clear standards from the National Institute for Clinical Excellence in the UK. They have set standards of one week from first symptom to referral and two weeks from symptom to procedure.

Radiation-induced Carotid Stenotic Lesions have a more Stable Phenotype than De Novo Atherosclerotic Plaques

2012-03-21

Abstract: Objective: To identify plaque characteristics of carotid artery radiation-induced stenosis.Materials and methods: Nineteen carotid plaques were obtained during carotid endarterectomy (CEA) in 17 consecutive patients with prior cervical radiation therapy (XRT) (median interval 10 years) and compared with 95 matched control carotid plaques of patients without a history of XRT. The following histopathological factors were assessed: calcification, collagen, macrophages, smooth muscle cells, atheroma, microvessels and intraplaque haemorrhage. Association of individual histological parameters with XRT plaque was analysed through a multivariable regression model.Results: Less infiltration of macrophages (6/19 versus 60/95, adjusted p = 0.003) and a smaller lipid core size (Atheroma >10%: 10/19 versus 80/95, adjusted p = 0.006) were independently associated with XRT plaque, compared to non-XRT plaques.Conclusions: Carotid stenotic lesions in patients with previous cervical radiation are less inflammatory and more fibrotic than carotid atherosclerotic lesions in non-radiated patients.

C-type Natriuretic Peptide and its Receptors in Atherosclerotic Plaques of the Carotid Artery of Clinically Asymptomatic Patients

A. Kuehnl, J. Pelisek, J. Pongratz, H.-H. Eckstein — 2012-03-14

Abstract: Objectives: C-type natriuretic peptide (CNP) has anti-inflammatory, anti-proliferative and anti-migratory properties. No data exist on the presence of CNP in human atherosclerotic plaques of the carotid artery. Therefore, this study aimed to analyse qualitatively the distribution pattern and characteristics of CNP and its receptors in both, early and advanced human carotid plaques, as well as in stable and unstable lesions.In addition, the aim of this study was to evaluate CNP and its receptors as possible biomarkers to predict plaque stability in advanced lesions.Methods: Advanced carotid artery plaques of 40 asymptomatic patients (20 histologically stable and 20 histologically unstable) and early arteriosclerotic lesions of three patients were analysed.Results: Serum level of CNP was similar in patients with stable and unstable plaques (196 ± 19 pg ml−1 vs. 198 ± 25 pg ml−1, p = 0.948). Expression level of natriuretic peptide receptor 3 (NPR3) was significantly higher in unstable plaques compared to stable plaques (5.6 ± 1.8% vs. 1.7 ± 0.5%, p = 0.045). Expression levels of CNP and NPR2 were higher in unstable plaques but the differences were not statistically significant. The distribution pattern of CNP, NPR2 and NPR3 varied qualitatively between early and advanced carotid plaques. No relevant histological differences were observed with respect to plaque stability.Conclusions: This study shows the presence of CNP and its receptors in atherosclerotic plaques of human carotid artery, with increased expression of NPR3 in histologically unstable plaques. In this study, serum CNP was not associated with histological plaque stability. In future, larger studies are required to further evaluate whether proteins of the CNP axis would be useful as biomarkers.

Development of Off-the-shelf Stent Grafts for Juxtarenal Abdominal Aortic Aneurysms

T.A. Resch, N.V. Dias, J. Sobocinski, B. Sonesson, B. Roeder, S. Haulon — 2012-02-20

Abstract: Introduction: The use of EVAR for more complex aneurysm anatomy has become more widespread over the past decade. Fenestrated and branched stent grafts for the visceral and iliac segment show promising short- and midterm outcome and these procedures have become routine in many vascular centers. However, at present, such grafts are customized to the individual patient and planning and manufacturing leads to significant treatment delay subjecting the patients to the risk of rupture during the waiting period. The purpose of this report is to describe the first experience in treating juxta/suprarenal aneurysms using the first version of a new fenestrated stent graftMaterial and Methods: A fenestrated device was designed with two renal fenestrations, an SMA fenestration and a scallop for the coeliac artery. The renal arteries were designed with an inner 6 mm fenestration and an outer 15 mm diameter creating a dome to allow renal artery catheterization for a range of renal artery distribution. Seven patients with complex visceral artery anatomy were treated with customized stent grafts containing these pivot renal fenestrations.Results: Technical success was uniform with 100% target vessel catheterization and 0% 30-day mortality. In one case, the graft was displaced slightly during delivery resulting in a renal artery stent occlusion at 2 months postoperatively.Conclusions: The development of a modified fenestrated device has shown this to be feasible and it has the potential to reduce the need for extensive preoperative graft customization and establishing a true off the shelf platform for juxta- and suprarenal AAA.

Commentary on ‘Development of Off-the-shelf Stent Grafts for Juxtarenal Abdominal Aortic Aneurysms’

D.J. Adam, E.L.G. Verhoeven — 2012-04-05

The paper in this month's journal from Resch, Haulon and colleagues describes the first clinical experience using a pre-loaded fenestrated aortic stent-graft with pivot renal fenestrations in patients with complex abdominal aortic aneurysms (AAA). Regulatory issues required the endografts to be customised, but the paper clearly demonstrates the feasibility of Cook Medical's (Bloomington, Indiana) proposed ‘off-the-shelf’ fenestrated device. From a technical perspective, there are potential benefits associated with the novel pre-loaded pivot renal fenestrations. For example, in angulated necks, alignment of the fenestrations with the renal arteries may not be so crucial, the pivot fenestrations behaving like short cuffs and giving the clinician some room to manoeuvre. Unlike Cook's device which has three fenestrations for the superior mesenteric artery and both renal arteries, Endologix (Irvine, California) has developed an ‘off-the-shelf’ fenestrated device with two renal fenestrations and a scallop for the visceral vessels. While both manufacturers claim that the majority of short-necked and juxtarenal AAA can be treated using their graft, the triple fenestrated platform should be more versatile and allow the treatment of some suprarenal aneurysms as well. Specialist aortic units will likely have access to both double and triple fenestrated platforms allowing the treatment to be tailored to the patient and the aneurysm, thereby avoiding the unnecessary implantation of a complex endograft where a simpler device will suffice.

Selection, Thirty Day Outcome and Costs for Short Stay Endovascular Aortic Aneurysm Repair (SEVAR)

N. Al-Zuhir, J. Wong, I. Nammuni, G. Curran, T. Tang, K. Varty — 2012-03-28

Abstract: Background: Endovascular Aortic aneurysm Repair (EVAR) offers the potential for a reduced hospital stay. The aim of this study was to identify patients suitable for short stay EVAR (SEVAR) with a single night in hospital and document their outcome.Method: Patients for EVAR were assessed prospectively for SEVAR over a 21-month period using UK Day Surgery Guidelines. Joint anaesthetic and surgical approval were necessary for these patients to be included in this vascular pathway. Patients were admitted on the day of surgery with a designated care protocol for discharge the day after.Results: 101 patients were assessed for SEVAR. 33 (33%) patients met the criteria for SEVAR and 27 of these (81%) were successfully discharged one day post-operatively. Total SEVAR median LOS was one day (IQR = 0) versus four days (IQR = 2) for the standard EVAR group (P < 0.0001) reducing costs from £13,360 (CI = ±1074) to £9844 (CI = ±628). Increased utilisation of SEVAR during the study period led to reduced overall average EVAR costs, £12,102(CI = ±795) to £10,330(CI = ±757).Conclusion: SEVAR protocol reduces hospital stay for selected patients. The outcomes from a larger cohort of such patients require further study. This would identify whether SEVAR could be expanded to more patients.

Commentary on ‘Selection, Thirty Day Outcome and Costs for Short Stay Endovascular Aortic Aneurysm Repair (SEVAR)’

H.H. Dosluoglu, M.L. Dryjski — 2012-03-19

One of the most consistent findings of all studies comparing open and endovascular repair (EVAR) of AAA has been that EVAR patients very seldom need postoperative intensive care and their overall hospital length of stay (LOS) is significantly reduced. These two elements are essential to offset for the high cost of EVAR devices and make the procedure economically competitive, especially in those with significant co-morbidities. In the past, the mean LOS for EVAR patients ranged between 2.5 and 2.8 days; however, there is a strong trend in the USA to discharge patients on the first postoperative day (POD). The rapidly increasing popularity of percutaneous EVAR (PEVAR) was expected to have an impact on LOS, but the reported difference was not statistically significant. Nevertheless, majority of uncomplicated PEVAR patients, particularly those who undergo procedure under local anaesthesia, do remarkably well and can be safely discharged home the same day.

No Differences in Perioperative Outcome between Symptomatic and Asymptomatic AAAs after EVAR: An Analysis from the ENGAGE Registry

R.A. Stokmans, J.A.W. Teijink, P.W.M. Cuypers, V. Riambau, M.R.H.M. van Sambeek — 2012-03-23

Abstract: Aim: This study aimed to compare the differences in perioperative outcome after endovascular repair of symptomatic abdominal aneurysms (S-AAAs) and elective non-symptomatic AAAs (E-AAAs). Data from the ENGAGE Registry were used for the analysis.Methods: Between March 2009 and December 2010, 1200 AAA patients were enrolled from 79 sites in 30 countries and treated with an Endurant Stent Graft. S-AAAs defined as AAAs accompanied by abdominal or back pain, without rupture, were present in 185 (15.4%) patients and E-AAAs in 1015 (84.6%) patients. Multivariate logistic regression was used to compare results.Results: At baseline, E-AAA patients had larger aneurysms on average (P = 0.006) and scored higher ASA classification more often (P = 0.001). Further analyses were corrected for baseline differences. Operation time and technical success were comparable, and S-AAAs were admitted to the Intensive Care Unit (ICU) as often as E-AAAs (35.7% vs. 33.4%, P = 0.479). Post-operative hospitalisation was similar (4.83 ± 5.29 in E-AAAs and 4.37 ± 3.49 in S-AAAs, P = 0.360). No differences in the occurrence of major adverse events, including mortality, within the 30-day post-implantation were seen between S-AAA and E-AAA patients, respectively, 3.2% and 4.2% (P = 0.572).Conclusion: With contemporary devices and technical proficiency, there is no difference in outcome between symptomatic AAA and elective non-symptomatic AAA patients if treated with endovascular techniques.

Commentary on ‘No Differences in Perioperative Outcome between Symptomatic and Asymptomatic AAAs after EVAR: An Analysis from the ENGAGE Registry’

L. Harris — 2012-03-27

Historically, patients with symptomatic AAA have had poorer outcomes than those with elective repair. Dr Stockman and colleagues have presented a very important paper assessing the outcomes of patients treated by EVAR for symptomatic, nonruptured AAA, and compared them to patients treated for elective AAA by review of ENGAGE, a prospectively managed database for a single endovascular stent graft, Endurant.

Thrombogenicity of a New Injectable Biocompatible Elastomer for Aneurysm Exclusion, Compared to Expanded Polytetrafluoroethylene in a Human Ex Vivo Model

2012-03-21

Abstract: Objectives: Customized Aortic Repair (CAR) is a new concept for endovascular aortic aneurysm repair in which a non-polymerised elastomer is injected to fill the aneurysm sac around a balloon catheter. Amongst other variables, the thrombogenicity of the elastomer should be tested, before further clinical experiments can take place. The aim of this human ex vivo study was to measure the thrombogenicity of the elastomer and to compare it to expanded polytetrafluoroethylene (ePTFE).Design and materials: In a validated ex vivo model, non-anticoagulated blood was drawn from the antecubital veins of 10 healthy donors with a 19-gauge needle. It was drawn through elastomer tubes and through ePTFE Gore-Tex vascular grafts, both 60 cm long and with an inner diameter of 3 mm.Methods: Fibrinopeptide A (FPA) and P-selectin expression was measured in blood samples, collected at the end of the grafts. After the experiments, the deposition of platelets and fibrin onto the grafts was visualised by scanning electron microscopy.Results: For these graft types, a progressive increase in FPA production was observed in time. No significant difference was observed between the elastomer and ePTFE grafts (p > 0.05). No increase in P-selectin expression, and thereby no platelet activation, was observed in the perfusate of either grafts (p > 0.05). By scanning electron microscopy, numerous platelet aggregates were observed on the ePTFE grafts, whereas just a few adhered platelets and no aggregates were observed in the elastomer grafts.Conclusions: The elastomer in its current formulation has a low thrombogenicity, comparable to ePTFE, making it an ideal substance for endovascular aneurysm sac filling. Further research should clarify the feasibility of CAR in vivo.

Challenging Narrow Distal Aorta in Abdominal Aortic Aneurysm – Endovascular Repair Using a Reversed Flared Endoprosthesis

T.R. Wyss, G. Heller, M. Furrer — 2012-03-29

Abstract: Introduction: Narrow aortic bifurcations are a challenging issue while treating abdominal aortic aneurysm by endovascular means. Off-the-shelf products are often not suitable and special considerations and custom-made endoprostheses are necessary.Report: Alternatively, some morphologies qualify for a flared tube graft. We report two successful aneurysm exclusions using custom-made (Anaconda, Vascutek/Terumo) step-down diameter grafts in patients with tight distal aortas without the need for pre-interventional endograft adjustments.Discussion: In these two cases, implantation of a custom-made proximally flared tube endograft in treating a localised abdominal aortic aneurysm with a narrow and calcified bifurcation seems feasible. They represent uncommon, yet challenging, issues worthy of attention.

Electromagnetic Tracking for Registration and Navigation in Endovascular Aneurysm Repair: A Phantom Study

A. de Lambert, S. Esneault, A. Lucas, P. Haigron, Ph. Cinquin, J.-L. Magne — 2012-04-09

Abstract: Objective: To assess the feasibility of using an electromagnetic tracking for both registration and navigation in endovascular aneurysm repair.Materials and methods: A registration process was implemented to align computed tomography (CT) data and electromagnetic tracking data. Two abdominal aortic aneurysm (AAA) phantoms were used, a rigid plastic AAA model (phantom A) and a soft silicon AAA model (phantom B). A pre-procedural CT volume was acquired for each phantom. Intra-operative simulation was performed by placing each phantom in the magnetic field of the tracking device. Using a modified electromagnetic catheter, a set of three-dimensional positions was acquired in the phantom's aortic lumen. Pre-procedural CT images and intra-procedural tracked positions were registered. Four reference points were used to calculate the registration accuracy of phantom A. Three surgeons simulated catheterisation of the left renal artery with phantom B using only image-guided procedure software.Results: The mean registration error was 1.3 mm (range 0.88–1.89). The median time for left renal catheterisation was 22 s (range 15–59).Conclusion: Registration of CT data and electromagnetic tracking data is feasible using catheter positions in the aorto-iliac structure as landmark. This navigation system could reduce X-ray exposure time and the use of contrast medium injections.

Diagnostic Laparoscopy for Early Detection of Acute Mesenteric Ischaemia in Patients with Aortic Dissection

2012-04-16

Abstract: Introduction: Recognition of acute mesenteric ischaemia (AMesI) in patients with aortic dissection (AoD) may be a challenge and exploratory laparotomy is often performed.Methods: We retrospectively analysed our experience with the use of diagnostic laparoscopy (DL) for the early detection of AMesI in patients with AoD, either undergoing medical treatment or after open/endovascular interventions.Results: Between 2004 and 2011, 202 consecutive AoDs were treated in our centre (71 acute type A AoD; 131 acute and chronic type B AoD). Among the 17 (8.4%) patients in which AMesI was suspected, nine (52.9%) were selected for DL. Three DLs were performed during medical treatment of patients with acute type B AoD, six after treatment of AoD (both surgical and endovascular). Three second-look DLs were also performed.Eight DLs were negative, three showed AMesI and the patients underwent successful emergent revascularisation. One DL was not conclusive and laparotomy was required. Among the eight patients not submitted to DL, one case of bowel infarction was recorded.Conclusions: In our series DL was feasible and safe. The low invasiveness and repeatability were the main advantages. Although additional experience is mandatory, DL seems a promising technique for the detection of AMesI in patients with AoD.

Porcine Model of Ruptured Abdominal Aortic Aneurysm Repair

2012-03-14

Abstract: Objectives: To validate a porcine model of ruptured abdominal aortic aneurysm (rAAA) repair.Design: Experimental study.Methods: Ten experimental and five sham-operated pigs were studied. Instrumentation for cardiac output (CO) measurement, regional blood flow (renal-REN and portal-PORT) and blood sampling (inferior vena cava (IVC), renal and portal vein) was done. Microcirculation was visualised sublingually and in ileostoma. Protocol: simulation of rAAA with bleeding (mean arterial pressure (MAP) 45 mmHg) and increased abdominal pressure (25 mmHg) for 4 h; 2 h of infrarenal clamp with shed blood retransfusion; 11 h of post-surgery care.Results: Six experimental pigs completed the protocol and are presented. Bleeding decreased CO to 95%, PORT to 80% and REN to 10% of baseline. From clamping on CO and PORT increased above baseline whereas REN (47%) with creatinine clearance remained compromised till the end. Microcirculation was affected more in ileum than sublingually. Approximately threefold increase in cytokines (tumour necrosis factor-α (TNF-alpha), interleukin (IL)-6 and IL-10) and oxidative stress markers (thiobarbituric acid-reactive substances (TBARs) and 4-hydroxy-2-trans-nonenal (HNE) was observed. Only mild increase in IL-6 and TBARs was observed in sham-operated animals. Organ histology did not reveal differences between groups.Conclusions: This near-lethal model of rAAA induced expected severe deterioration of haemodynamics and metabolism accompanied with a moderate inflammatory and oxidative stress response.

Estimation of Running Capacity can Likely be Removed from Questionnaires Estimating Walking Impairment in Patients with Claudication

2012-03-05

Abstract: Objective: The Estimating Ambulation Capacity by History-Questionnaire (EACH-Q) and the Walking Impairment Questionnaire (WIQ) are used to estimate maximal walking distance (MWD). The EACH-Q and WIQ included 4 and 14 items respectively, among which one item dealing with running capacity. We hypothesised that this item was of little interest in patients with claudication.Design: The WIQ and EACH-Q were self-completed and corrected before a constant load (3.2 km h−1; 10% slope) treadmill tests, maximised to 15 min.Patients: 371 patients (298 males/73 females, 62.9 ± 11.2 years).Methods: The number of errors (duplicate, absent or paradoxical answers to one item) and correlation of questionnaire scores with MWD on treadmill were calculated, before and after skipping the answer to the running item.Results: The proportion of questionnaires with errors was 27% with the EACH-Q and 48% with the WIQ. Two-hundred and twenty-one (59.6%) and 245 (66%) out of 371 patients reported to be unable to run, for the EACH-Q and WIQ, respectively. The rate of errors was reduced by 15% for the EACH-Q (p < 0.05) when skipping the running item for scoring. The correlation coefficients between the MWD and the questionnaire scores were 0.449 and 0.485 for the EACH-Q and were 0.571 and 0.572 for the WIQ, before and after skipping the running item, respectively.Conclusion: Most of our patients reported to be unable to run and skipping the running item reduce the rate of errors in self-completing the questionnaires without impairing the correlation of questionnaire scores with treadmill results. It is likely that the running item could be removed from the WIQ and EACH-Q questionnaires.

Laparoscopic versus Open Approach for Aortobifemoral Bypass for Severe Aorto-iliac Occlusive Disease – A Multicentre Randomised Controlled Trial

J. Tiek, P. Remy, T. Sabbe, C. D’hont, S. Houthoofd, K. Daenens, I. Fourneau — 2012-03-02

Abstract: Objectives: To investigate differences between open and laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease on postoperative morbidity and mortality.Design: A multicentre randomised controlled trial.Methods: Between January 2007 and November 2009, 28 patients with severe aorto-iliac occlusive disease (TASC II C or D) were randomised between laparoscopic and open approach at one community hospital and one university hospital (TASC = Trans-Atlantic Inter-Society Consensus on the Management of Peripheral Arterial Disease).Results: The operation time was longer for the laparoscopic approach (mean 4 h 19 min (2 h 00 min to 6 h 20 min) vs. 3 h 30 min (1 h 42 min to 5 h 11 min); p = 0.101)). Nevertheless, postoperative recovery and in-hospital stay were significantly shorter after laparoscopic surgery. Also oral intake could be restarted earlier (mean 20 h 34 min (6 h 00 min to 26 h 55 min) vs. 43 h 43 min (19 h 40 min to 77 h 30 min); p = 0.00014)) as well as postoperative mobilisation (walking) (mean 46 h 15 min (16 h 07 min to 112 h 40 min) vs. mean 94 h 14 min (66 h 10 min to 127 h 23 min); p = 0.00016)). Length of hospitalisation was shorter (mean 5.5 days (2.5–15) vs. mean 13.0 days (7–45); p = 0.0095)). Visual pain scores and visual discomfort scores were both lower after laparoscopic surgery. Also return to normal daily activities was achieved earlier. There were no major complications in both groups.Conclusion: Laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease is a safe procedure with a significant decrease in postoperative morbidity and in-hospital stay and earlier recovery.

Early and Late Results of Ex Vivo Repair and Autotransplantation in Solitary Kidneys

J. Morin, B. Chavent, A. Duprey, J.N. Albertini, J.P. Favre, X. Barral — 2012-04-16

Abstract: Introduction: Autotransplantation of a solitary kidney provides an excellent opportunity to study the immediate and long-term consequences of intra-operative renal ischaemia. The purpose of this report is to describe a series of nine patients who underwent ex vivo repair and autotransplantation on solitary kidneys.Patients and methods: The series included six females and three males with a mean age of 36 years. Seven of the nine patients were hypertensive (mean number of anti-hypertensive agents: 3). Two patients had chronic renal failure (serum creatinine levels: 192 and 205 μmol l−1). All arteries except one with Takayasu disease were affected by dysplastic aneurysm or fibrodysplasia lesion. There was no atherosclerotic lesion. The mean number of renal artery branches repaired was 3.1 per patient. Mean duration of ischaemia was 161 min.Results: Creatinaemia increased in all patients following the procedure. Creatinaemia and clearance returned to preoperative values between the 3rd and 10th postoperative days. One kidney was lost due to renal vein thrombosis. Late findings indicated that renal function was stable and there was no deterioration in the function of the autotransplanted kidneys after a follow-up period of 89 months. Preoperative versus postoperative creatinaemia and clearance levels were respectively 111 vs. 105 μmol l−1 and 66.9 vs. 62.0 ml min−1 (ns). During the same time, the mean number of anti-hypertensive agents decreased slightly from 3 to 2.5.Conclusion: In this small series of patients who underwent ex vivo repair and autotransplantation on solitary kidneys, intra-operative renal ischaemia had no detrimental effect on renal function.

Comparative Stability of Sodium Tetradecyl Sulphate (STD) and Polidocanol Foam: Impact on Vein Damage in an In-vitro Model

2012-04-16

Abstract: Objectives: To compare the half-life of STD and Polidocanol air-based foams and the damage they inflict upon human great saphenous vein in an in-vitro model.Methods: The time for the volume of 3% STD and polidocanol foams to reduce by 10% (T90) and 50% (T50) was recorded in an incubator at 37 °C.Segments of proximal GSV harvested during varicose vein surgery were filled with foam for 5 or 15 min. Histological analysis determined percentage endothelial cell loss and depth of media injury.Results: Median (±IQR) T90 and T50 for polidocanol were 123.3 s (111.7–165.6) and 266.3 s (245.6–383.1) versus 102.03 s (91.1–112) and 213.13 s (201–231.6) for STD (T90 p = 0.008, T50 p = 0.004).Median endothelial loss with polidocanol was; 63.5% (62.2–82.8) and 85.9% (83.8–92.5) versus 86.3% (84.8–93.7) and 97.64% (97.3–97.8) for STD after 5 and 15 min (p = 0.076 and p = 0.009).The median depth and % media thickness injured were 0 μm (0–0 μm) and 0% for both assessments with polidocanol versus 37.4 μm (35.3–45.8 and 43.4 μm (42.1–46.7) and 3.5% (3.1–3.6) and 5.3% (3.7–6.0) after 5 and 15 min for STD (p < 0.01 for all comparisons).Conclusion: Although polidocanol foam shows greater stability than STD foam perhaps remaining in the vein for longer, endothelial cell loss and damage to the media were significantly greater with STD.

Thermal Ablation in the Management of Superficial Thrombophlebitis

M.A. Enzler, D. Russell, J. Schimmelpfennig — 2012-03-14

Abstract: Introduction: In superficial thrombophlebitis (ST), saphenous high ligation and stripping may be indicated. Endovenous thermal ablation (ETA) was hitherto not reported for ST management. We treated three ST patients using ETA and describe one in more detail.Report: An 81 year-old man with ST at the medial lower leg and a refluxing GSV underwent ETA of the GSV. Since thrombi were present, the GSV was punctured at the inguinal crease and the laser catheter introduced caudad in order to prevent embolism.Discussion: In ST, ETA might prevent thrombus expansion and embolism. However, this approach requires further optimisation and scrutiny.

Postoperative Treatment of Critical Limb Ischemia

O. Gokalp, L. Yilik, I. Yurekli, S. Gur, A. Gurbuz — 2012-04-20

We congratulate the authors for their study. Although the results of this study are quite valuable with a satisfying number of patients, we think that it is essential to define which therapies were employed postoperatively, except angiosome concept. We believe that the treatment of critical limb ischemia (CLI) cannot be accomplished by surgery alone. These patients typically have ulcers in their extremities prior to surgery as well. It is well known that postoperative systemic or specific treatments for these ulcers affect minor and major amputation rates. For instance, there are many studies suggesting that Cilostazole and prostanoids reduce amputation rates in patients undergoing intervention for CLI. Hyperbaric oxygen therapy, another method performed with the same purpose, has been showed to prove beneficial for ischemic ulcers resistant to successful surgery in patients with CLI. In the light of these data, we feel to underline that the results of vascular surgical interventions particularly for CLI must be assessed together with postoperative treatments.

Selected Abstracts from the June Issue of the Journal of Vascular Surgery

2012-06-01

Frédéric Cochennec, Isabelle Javerliat, Isabelle Di Centa, Olivier Goëau-Brissonnière, Marc Coggia Objective: The feasibility of total laparoscopic abdominal aortic aneurysm (AAA) repair has been well established. In a previous case-control study, we showed that the postoperative courses of total laparoscopic and open AAA repairs were similar. The purpose of this study was to compare the long-term results of these techniques in the same cohort of patients.

Infrarenal Aortic Coarctation as a Cause for Hypertension

R.J. van der Vijver, A.P. Schouten van der Velden, J.J. Fütterer, P. Berger — 2012-04-09

We present a case report of a 29-year-old male who was diagnosed with asymptomatic hypertension. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) showed a stenotic aorta, with extensive collateral flow called the middle aortic syndrome. The aetiology of middle aortic syndrome is poorly understood. Although treatment is preferably surgical, our case shows that medical therapy can be successful.

A Modified Technique of Open Surgical Treatment for Aneurysmal Sac Enlargement after Endovascular Repair

A. Hiraoka, H. Yoshitaka, G. Chikazawa, A. Ishida, T. Totsugawa, M. Kuinose — 2012-03-28

Introduction: Although several articles have reported the successful treatment of an abdominal aortic aneurysm (AAA) enlargement after endovascular aortic repair (EVAR) due to endoleak or endotension, the strategy to treat this type of complication is still controversial.

Endobypass Using a Heparin-bonded Covered Stent to Treat Upper Limb Claudication due to Axillary Artery Occlusion Following Axillofemoral Bypass

A. Chaudhuri — 2012-03-26

Introduction: Post-surgical axillary artery occlusion may present with upper limb symptoms requiring intervention. Report: A 76-year-old male had previously undergone left axillofemoral bypass for lower limb ischemia. Following an initial presentation with brachial thromboembolism, he re-presented with left axillary artery occlusion manifesting as upper limb claudication significantly affecting activities of daily living. The axillary artery was successfully recanalised following deployment of a 10 × 50mm Viabahn endoprosthesis with complete symptomatic resolution.

Not Just a Popliteal Aneurysm: A Case of Metastatic Epithelioid Angiosarcoma

A. Cristaudo, C. Steffen — 2012-04-09

Introduction: Popliteal aneurysms are the second most common aneurysm. This case report describes a case of angiosarcoma in a popliteal aneurysm, illustrating the importance of post-operative surveillance in expanding popliteal aneurysms post-treatment.

Forthcoming Events

2012-06-01