European Journal of Vascular & Endovascular Surgery

Editorial Board

2010-09-01

EJVS Newsletter

2010-09-01

Vascular Surgeon in 2010: A Co-head Physician or a Leader?

C. Setacci — 2010-07-05

Once, a man said “History doesn’t exist, but only biographies.” In what appears to be a mere syntactic difference lies hidden a more profound meaning: although some events seem to be uncontrollable by mankind, history is still written by men.

Capturing the Essence of Developing Endovascular Expertise for the Construction of a Global Assessment Instrument

B. Bech, L. Lönn, T.V. Schroeder, S.B.E.W. Räder, C. Ringsted — 2010-06-07

Abstract: Objectives: To explore what characterises the development of endovascular expertise and to construct a novel global assessment instrument.Design: Literature review and an experimental study.Materials and methods: The literature was searched for information regarding available global rating scales (GRSs); scientific societies’ official statements on endovascular competence; and task analyses of endovascular procedures. In the experimental study, clinicians performed a video-recorded simulated iliac-artery stenting procedure. Subsequently, by using the method of retrospective verbalisation, the clinicians were interviewed while watching their performance on video commenting on key issues of the construct. Data from all sources were analysed, categorised and synthesised into a novel rating scale.Results: Available GRSs primarily included technical aspects of performance, whereas the competence statements, task analyses and clinicians’ perceptions added a range of non-technical aspects. The novel rating scale SAVE (Structured Assessment of endoVascular Expertise) differs from prior scales by including issues of pre-planning; prediction of challenges; preparation of tools; management of imaging presentation; distinction of technical skills into external and internal control according to operator focus of visual attention; adaptation of strategy; clinical decision making; use of assistant; complications; inter-personal skills; and post-procedural planning.Conclusions: The essence of developing endovascular expertise goes far beyond mere technical aspects.

Synchronous Cardiac and Carotid Revascularisation: The Devil is in the Detail

A.R. Naylor — 2010-06-21

Abstract: Background: Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure.Methods: Retrospective audit of prospectively acquired data in 132 consecutive patients undergoing synchronous carotid endarterectomy and cardiac surgery.Results: Overall 30-day rates of mortality, ipsilateral stroke and any stroke were 5.3%, 1.5% and 3% respectively. The 30-day rate of death/stroke was 6.8%. In 51 patients with a prior history of stroke/TIA, the 30-day rate of death/stroke was 5.9%, compared with 7.4% in neurologically asymptomatic patients. The majority (57%) had significant bilateral disease and underwent their combined procedure in the presence of a significant, non-operated (asymptomatic) contralateral stenosis (50–99% = 75, 60–99% = 54, 70–99% = 32). Only one patient (90–99% stenosis) suffered a post-operative stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.Conclusions: Patients undergoing synchronous procedures incurred a low rate of procedural stroke, perhaps justifying this management approach. However, an alternative and more critical analysis suggested that the risk of procedural stroke in patients with significant (non-operated) contralateral asymptomatic carotid disease was extremely low. This challenges the assumption that asymptomatic carotid disease is an important cause of stroke during cardiac surgery.

The Need for Questionnaires in Vascular Surgery: The Paradigm of Carotid Revascularisation

G.J. de Borst, A. Froio, G. Biasi, F.L. Moll — 2010-07-20

As a mechanism for obtaining information and opinion, questionnaires have a number of advantages compared with other evaluation tools: (1) nearly everyone has some experience of completing questionnaires; (2) questionnaires are easy to analyse when properly designed; (3) they are very cost-effective, especially for studies involving large sample sizes and large geographic areas; (4) bias is reduced by uniform question presentation; and (5) data collection is performed anonymously.

An Update of the Role of Endovascular Repair in Blunt Carotid Artery Trauma

K.G. Moulakakis, S. Mylonas, E. Avgerinos, T. Kotsis, C.D. Liapis — 2010-06-23

Abstract: Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40–80% and mortality rate of 25–60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

Determinants of Radiation Exposure during EVAR

S.A. Badger, C. Jones, C.S. Boyd, C.V. Soong — 2010-06-21

Abstract: Objectives: Endovascular aneurysm repair (EVAR) is an established method of aortic aneurysm repair, in favourable anatomical configurations. It does however expose patients to radiation. The study aim was to determine if the aneurysm neck morphology influenced radiation exposure.Patients and methods: All elective and emergency EVAR patients were identified. Elective patients had a bifurcated stent-graft deployed, while emergency patients were repaired with an aorto-uni-iliac stent-graft and fem–fem crossover bypass. Proximal and distal aortic neck diameters, neck length, neck angles and sac diameter were recorded, with the radiation dose, screening time and contrast volume. The two subgroups of elective and emergency patients were compared and correlation between anatomical and radiological parameters calculated by using Pearson’s correlation coefficient.Results: 320 (270 male) elective patients and 64 (55 male) emergency patients from October 1998 to October 2008 underwent EVAR. The mean proximal (p = 0.004) and distal (p = 0.01) neck diameters were smaller and mean sac diameter (p < 0.0001) was greater in emergencies. No difference between groups existed in the neck length (p = 0.36) and suprarenal diameter (p = 0.30), sagittal (p = 0.05) and coronal (p = 0.62) neck angles. The screening time (p = 0.053) and contrast volume (p = 0.04) were lower, with a slightly higher radiation dose (p = 0.12) in emergencies. There was no definite correlation between the seven anatomical and three radiological parameters.Conclusion: While radiation exposure is different in emergency patients, this is thought due to surgical technique rather than the aneurysm neck morphology.

Pulsatile Distension of the Proximal Aneurysm Neck is Larger in Patients with Stent Graft Migration

J.W. van Keulen, F.L. Moll, G.K. Barwegen, E.P.A. Vonken, J.A. van Herwaarden — 2010-06-21

Abstract: Purpose: The proximal abdominal aortic aneurysm (AAA) neck expands significantly during the cardiac cycle, both before and after endovascular aneurysm repair (EVAR). Clinical consequences of this pulsatility were anticipated but have never been reported. This study investigated whether there is a relation between stent graft migration and preoperatively measured pulsatility of the proximal aneurysm neck.Methods: EVAR patients with a preoperative dynamic computed tomography angiography (CTA), an immediate postoperative, and a CTA at 3 years after EVAR were included. The preoperative dynamic CTAs consisted of eight images per heartbeat. Aortic diameter and area changes per heartbeat were measured at two levels: (A) 3 cm above and (B) 1 cm below the most distal renal artery. Postoperatively, the distance between the most distal renal artery and the most proximal stent graft ring was measured. Two patient groups were distinguished according to whether migration during follow-up occurred (group 1) or had not occurred (group 2). The aneurysm neck dynamics of the two groups were compared by using the t-test for unpaired data and multivariable logistic regression analyses were performed. Mean values are presented with the standard deviation.Results: Included were 26 patients (19 Talent, 6 Excluder and 1 Lifepath). Stent graft migration of ≥5 mm occurred in 11 patients (group 1). The pulsatility of the AAA neck in these patients was compared with the pulsatility in 15 patients with no graft migration (group 2). There were no significant differences in aortic neck characteristics (angulation, length and diameter) or degree of stent graft oversizing between the two groups. At level A in group 1 versus group 2, the diameter increase during the cardiac cycle was 2.0 ± 0.3 versus 1.7 ± 0.3 mm and the aortic area increase was 49 ± 15 versus 33 ± 12 mm2. At level B in group 1 versus group 2, the diameter increase per heartbeat was 1.8 ± 0.3 versus 1.6 ± 0.4 mm, and the area increase was 37 ± 10 versus 25 ± 15 mm2. The heartbeat-dependent diameter and area changes at both levels were significantly higher in group 1 compared with group 2. Multivariate regression analysis showed suprarenal aortic pulsatility was a significant predictor for stent graft migration after 3 years.Conclusion: The preoperative heartbeat-dependent aneurysm neck distension is significantly associated with stent graft migration after 3 years. The aortic pulsatility in patients with stent graft migration is significantly higher than the pulsatility in patients without stent graft migration.

A Computational Study of the Magnitude and Direction of Migration Forces in Patient-specific Abdominal Aortic Aneurysm Stent-Grafts

D.S. Molony, E.G. Kavanagh, P. Madhavan, M.T. Walsh, T.M. McGloughlin — 2010-06-23

Abstract: Objectives: Endovascular aneurysm repair for abdominal aortic aneurysm (AAA) is now a widely adopted treatment. Several complications remain to be fully resolved and perhaps the most significant of these is graft migration. Haemodynamic drag forces are believed to be partly responsible for migration of the device. The objective of this work was to investigate the drag forces in patient-specific AAA stent-grafts.Methods: CT scan data was obtained from 10 post-operative AAA patients treated with stent-grafts. 3D models of the aneurysm, intraluminal thrombus and stent-graft were created. The drag forces were determined by fluid-structure interaction simulations. A worst case scenario was investigated by altering the aortic waveforms.Results: The median resultant drag force was 5.46 N (range: 2.53–10.84). An increase in proximal neck angulation resulted in an increase in the resultant drag force (p = 0.009). The primary force vector was found to act in an anterior caudal direction for most patients. The worst case scenario simulation resulted in a greatest drag force of 16 N.Conclusions: Numerical methods can be used to determine patient-specific drag forces which may help determine the likelihood of stent-graft migration. Anterior–posterior neck angulation appears to be the greatest determinant of drag force magnitude. Graft dislodgement may occur anteriorally as well as caudally.

Virtual Angioscopy and 3D Navigation: A New Technique for Analysis of the Aortic Arch after Vascular Surgery

2010-07-09

Abstract: Purpose: Anatomy of the aortic arch is highly variable and can be drastically altered by surgical or endovascular procedures. Detailed analysis of computed tomography (CT) scans is facilitated by reconstruction techniques such as virtual angioscopy (VA). In the present study, we have evaluated the benefit of VA for the assessment of aortic arch abnormalities in patients with prior surgical or endovascular procedures.Material and methods: We analysed post-procedural CT scans available in 103 patients who underwent thoracic aortic procedures between 2006 and 2009 at our institution. Patients were classified into three groups: surgical (group A, n = 26), hybrid (group B, n = 27) and endovascular (group C, n = 50), procedures. A 64 LightSpeed® volume computed tomography (VCT) multidetector-row computed tomography was used, allowing maximal intensity projection, maximal projection rendering imaging and three-dimensional (3D) rendering of images. VA reconstruction was performed by applying volume-rendered thresholds and spatial rendering to generate endoluminal views.Results: Multiplanar reformations (MPRs) detected 46 abnormalities in 39 patients: inadequate apposition of the proximal rim of a stent-graft (n = 21), abnormalities of the stent-graft itself (n = 11), aortic aneurysm (n = 6), residual intimal tears (n = 5) and secondary dissection (n = 3). VA provided additional information in 76% of cases (35/46) and was more contributive after endovascular repair than after open repair (group A: 54% (7/14), group B: 75% (9/12), group C: 95% (19/20)). VA improved localisation of abnormalities with respect to supra-aortic vessels, measured inadequate stent-graft apposition in relation to the aortic wall and precisely analysed kinking or inadequate apposition of overlapping stent grafts. VA diagnosed three additional abnormalities: two false aneurysms and one retrograde dissection developed on a suture line.Conclusions: VA conceptualises planar images by 3D reconstruction. It provides additional information in comparison with conventional CT scans by allowing precise localisation of abnormalities with respect to the aortic wall itself and supra-aortic vessels. Furthermore, it facilitates analysis of abnormalities in case of overlapping stent grafts.

Accuracy of FDG-PET–CT in the Diagnostic Work-up of Vascular Prosthetic Graft Infection

2010-06-24

Abstract: Objectives: To investigate the diagnostic accuracy of fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) compared with computed tomography (CT) scanning and added value of fused FDG-PET–CT in diagnosing vascular prosthetic graft infection.Design: Prospective cohort study with retrospective analysis.Materials: Twenty five patients with clinically suspected vascular prosthetic infection underwent CT and FDG-PET scanning.Methods: Two nuclear medicine physicians assessed the FDG-PET scans; all CT scans were assessed by two radiologists. Fused FDG-PET/CT were judged by the radiologist and the nuclear medicine physician. The concordance between CT and FDG-PET and the inter-observer agreement between the different readers were investigated.Results: Fifteen patients had a proven infection by culture. Single FDG-PET had the best results (sensitivity 93%, specificity 70%, positive predictive value 82% and negative predictive value 88%). For CT, these values were 56%, 57%, 60% and 58%, respectively. Fused CT and FDG-PET imaging also showed high sensitivity and specificity rates and high positive and negative values. Inter-observer agreement for FDG-PET analysis was excellent (kappa = 1.00) and moderate for CT and fused FDG-PET–CT analysis (0.63 and 0.66, respectively).Conclusion: FDG-PET scanning showed a better diagnostic accuracy than CT for the detection of vascular prosthetic infection. This study suggests that FDG-PET provides a useful tool in the work-up for diagnosis of vascular prosthetic graft infection.

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery

2010-06-28

Abstract: Objectives: Smoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers.Design: Cohort study.Methods: Data of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ).Results: After adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28–1.43; PAQ: OR = 0.76, 95% CI = 0.35–1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42–1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09–3.17; PAQ: OR = 1.63, 95% CI = 1.00–2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72–1.90).Conclusions: There was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention.

Comments regarding ‘Measuring Effects of Smoking and Smoking Cessation in Patients with Vascular Disease’

D. Lindström — 2010-07-05

In this issue of the journal Hoogwegt et al. describes the results of smoking cessation on quality of life (QoL) after vascular surgery. This is an ambition they should be applauded for; smoking cessation is most often recommended but seldom evaluated. In their cohort of patients they report QoL five years after surgery related to patients smoking status at three years after surgery. In summary they found that smoking cessation did not impair QoL among patients undergoing vascular surgery, (in contrast to what many smokers state as an argument to continue smoking). They also found that current smokers have worse QoL than the combined group of ex-smokers and never smokers. This is important since they all have advanced vascular disease, but despite this it is possible to improve QoL among smokers.

Dysfunctional Vasa Vasorum in Diabetic Peripheral Artery Obstructive Disease with Critical Lower Limb Ischaemia

2010-05-31

Abstract: Objectives and design: To establish whether in diabetic patients with peripheral artery obstructive disease (PAOD) vasa vasorum (vv) neoangiogenesis is altered with increased arterial damage.Materials: Thirty-three patients with PAOD and critical lower limb ischaemia, 22 with type II diabetes.Methods: Immunohistochemistry for endothelial cell markers (CD34 and von Willebrand Factor); real-time reverse transcription polymerase chain reaction (RT-PCR) to quantify arterial wall expression of vascular endothelial growth factor (VEGF); enzyme-linked immunosorbent assay (ELISA) to assess blood VEGF; flow cytometry to detect circulating endothelial cells (CECs).Results: Patients with PAOD and diabetes have a higher frequency (60% vs. 45%) of advanced atherosclerotic lesions and a significant reduction (p = 0.0003) in CD34+ capillaries in the arterial media. Adventitial neoangiogenesis was increased equally (CD34+ and vWF+) in all patients. Likewise, all patients have increased CEC and VEGF concentration in the blood as well as in-situ VEGF transcript expression.Conclusions: Patients with PAOD have remarkable arterial damage despite increased in-situ and circulating expression of the pro-angiogenic VEGF; a dysfunctional vv angiogenesis was seen in diabetics which also showed a higher frequency of parietal damage; it is suggested that in diabetic arterial wall, injury is worsened by vv inability to finalise an effective VEGF-driven arterial wall neoangiogenesis.

The Next 10 years in the Management of Peripheral Artery Disease: Perspectives from The ‘PAD 2009’ Conference

2010-06-16

Abstract: Objectives: To briefly inform on the conclusions from a conference on the next 10 years in the management of peripheral artery disease (PAD).Design of the Conference: International participation, invited presentations and open discussion were based on the following issues: Why is PAD under-recognised? Health economic impact of PAD; funding of PAD research; changes of treatment options? Aspects on clinical trials and regulatory views; and the role of guidelines.Results and Conclusions: A relative lack of knowledge about cardiovascular risk and optimal management of PAD patients exists not only among the public, but also in parts of the health-care system. Specialists are required to act for improved information.More specific PAD research is needed for risk management and to apply the best possible evaluation of evidence for treatment strategies. Better strategies for funding are required based on, for example, public/private initiatives.The proportion of endovascular treatments is steadily increasing, more frequently based on observational studies than on randomised controlled trials. The role of guidelines is therefore important to guide the profession in the assessment of most relevant treatment.

Angiogenic Peptides Improve Blood Flow and Promote Capillary Growth in a Diabetic and Ischaemic Mouse Model

A. Raiter, Z. Bechor, M. Kleiman, D. Leshem-Lev, A. Battler, B. Hardy — 2010-03-12

Abstract: Objectives: It is a common clinical observation that collateral vessel development is impaired in diabetic patients with ischaemic vascular diseases. Consequently, alternative revascularisation strategies in diabetic patients are needed. This study presents the effect and mechanism of new peptide therapeutic angiogenesis in an ischaemic and diabetic mouse model.Design: Streptozocin-injected mice that had undergone hind-limb ischaemia were treated with angiogenic peptides. Blood flow restoration was calculated by laser Doppler imager and corroborated by histological section. For the mechanism study, endothelial cells were exposed to hypoxia and high glucose concentrations to study the effect of the peptides on proliferation and anti-apoptosis.Results: The peptides significantly restored blood perfusion 21 days after surgery in the diabetic mice (p < 0.01) by neo-vascularisation, corroborated by an increase in capillary density. In addition, the peptides induced the proliferation of hypoxic endothelial cells (p < 0.01) and protected the cells from apoptosis in high glucose cultures.Conclusions: This is the first approach for treatment of ischaemic vascular disease with peptides in a diabetic mouse model.

Ultrasound Guided Foam Sclerotherapy: Factors Associated with Outcomes and Complications

S.C. Thomasset, Z. Butt, S. Liptrot, B.J. Fairbrother, K.R. Makhdoomi — 2010-05-26

Abstract: Objectives: In recent years ultrasound guided foam sclerotherapy (UGFS) has become an increasingly popular treatment for varicose veins. Although many published series detail the results of UGFS, little is known about the factors which are associated with outcomes and complications. The aim of this study was to identify these factors.Design: A review of a prospectively collected database of UGFS which commenced in July 2007.Methods: A successful outcome was defined as complete occlusion of the target vein on duplex scanning at follow-up. Eight factors were assessed to determine whether they were associated with outcomes and complications. These factors were age, gender, compliance with post-procedure compression hosiery, previous varicose vein surgery, single or multiple sites of injection, concentration of sclerosant, volume of sclerosant and pre-procedure severity score.Results: Between July 2007 and July 2009, a total of 126 patients (60 men, 66 women) attended follow-up visits and had a post-procedure duplex scan. Targets for UGFS included the great saphenous vein (n = 75), small saphenous vein (n = 13) and anterior accessory great saphenous vein (n = 8). The remainder of procedures involved other veins or more than a single target vein. The median timing of follow-up was 3 months (range 1.5–14 months) with duplex scans revealing complete occlusion of the target vein in 79% of patients. The only factor associated with a successful outcome was compliance with post-procedure compression hosiery (p < 0.05). The most frequently encountered complications following UGFS were skin staining (28%), superficial thrombophlebitis (18%) and pain (14%). The only factor associated with post-UGFS complications was female gender (p < 0.05). When complications were analysed in isolation female gender was also significantly associated with skin staining (p < 0.05), but no other complication.Conclusions: These data suggest that compliance with post-procedure compression hosiery and gender are important factors associated with a successful outcome and reported complications following UGFS, respectively.

Energy Delivery During 810 nm Endovenous Laser Ablation of Varicose Veins and Post-procedural Morbidity

D. Carradice, F.A.K. Mazari, A. Mekako, J. Hatfield, V. Allgar, I.C. Chetter — 2010-05-31

Abstract: Aim: The durability of occlusion post endovenous laser therapy (EVLT) for varicose veins is linked to the magnitude of energy delivered to the vein and consequently increasing amounts of energy are employed. The aim of this study is to establish whether increasing the energy results in greater periprocedural morbidity or complications.Methods: Linear and logistic regression models were built to study the effect of energy delivery on outcome. The models controlled for age, gender, BMI, pre-operative quality of life and vein dimension. The outcomes were pain and analgesia requirement in week 1, change in disease specific quality of life (Aberdeen varicose vein questionnaire (AVVQ), change in generic quality of life (Short Form-36 (SF-36) and Euroqol (EQ5D)at week 1 and 6 and complication rates. The sample size calculation established that 115 patients would be required to detect any significant relationship.Results: 232 patients were included. The mean (range) age was 50 (18–83) years. 63% were women. The mean (range) energy delivery was 89.8 (44.5–158.4) J/cm. There was no significant effect on any outcome related to increasing energy delivery.Conclusion: Up to 160J/cm, increasing energy delivery has no significant effect upon the morbidity or complications of EVLT for superficial venous insufficiency.

Clinical Presentation and Patterns of Venous Reflux in Thai Patients with Chronic Venous Insufficiency (CVI)

2010-06-21

Abstract: Objective: To study the extent of chronic venous insufficiency (CVI) in Thai patients by assessing venous clinical severity scores (VCSSs), venous disability scores (VDSs) and prevalence of lower limb venous reflux in a cohort of patients attending a vascular surgery clinic.Design: Prospective comparative cohort study.Material: All patients presenting with CVI (Clinical, Etiology, Anatomy and Pathophysiology (CEAP) C4–6) in our vascular surgery clinic between October 2006 and December 2008 were enrolled and compared with the same number of control patients.Method: A standardised interview was conducted to document each patient’s history of venous disease, VCSS and VDS. Duplex ultrasonography of selected superficial and deep veins was performed.Results: There were 41 patients, mean age 58 years and a mean body mass index (BMI) of 26.7. Of 58 limbs, 35%, 19% and 47% were of CEAP clinical stages C4, C5 and C6, respectively. Previous deep vein thrombosis (DVT) was reported by 7% and major leg trauma by 9% of patients. The mean VCSS was 9.7 and mean VDS was 1.0. VDS 2 or 3 were found in 10% of patients. The VCSS 2 and 3 for pain, oedema and inflammation were found in 22%, 26% and 0% of C6 legs. The prevalence of combined superficial and deep vein reflux was 71%. The prevalence of isolated superficial and deep vein reflux were 8% and 17%, respectively. One patient had iliac vein occlusion. Compared with the control group, risk factors that were found to be significant were physical findings of varicose veins, history of leg trauma, standing posture and BMI.Conclusions: Thai patients with CVI were relatively young. Visible varicose veins, pain, oedema and inflammation were uncommon and most patients could maintain their usual activities despite advanced venous disease. An association with obesity was not common. Despite a low prevalence of a history of previous DVT, the prevalence of deep vein reflux was high and commonly combined with superficial venous reflux.

Innovative Treatments in Chronic Venous Insufficiency: Endovenous Laser Ablation of Perforating Veins: A Prospective Short-term Analysis of 58 Cases

R.J. Hissink, R.M.G. Bruins, R. Erkens, M.L. Castellanos Nuijts, M. van den Berg — 2010-06-14

Abstract: Objective: To evaluate the efficacy of endovenous laser ablation of incompetent perforating veins.Study design: Prospective cohort study.Patients: A total of 58 perforating veins in 33 limbs of 28 patients were treated between March 2008 and February 2009 in an outpatient clinic setting. The average age was 65 years (range 30–81 years); 64% female; CEAP clinical stage C4 (67%), C5 (17%) and C6 (16%) (Clinica, Etiology, Anatomy and Pathophysiology, CEAP).Methods: All patients underwent a standardised clinical examination and duplex ultrasonography. Guided by duplex ultrasonography, the perforating veins were cannulated percutaneously and tumescent local anaesthesia was given. An 810-nm diode laser was used to deliver 14 W power. Mean total energy delivered was 187 (range 87–325) J. Three months post-treatment, all patients underwent a further duplex ultrasound examination, to determine the treatment outcome.Results: Occlusion of the perforating veins was achieved after 3 months in 78% of the cases. In the CEAP C6 group, four of five ulcers had healed after 6 weeks. No serious complications, including deep venous thrombosis, were encountered.Conclusions: Endovenous laser therapy for treating incompetent perforating veins is a safe and technically feasible technique. The initial occlusion rate is acceptable.

Incidence of Side Effects Using Carbon Dioxide–Oxygen Foam for Chemical Ablation of Superficial Veins of the Lower Extremity

2010-05-26

Abstract: Objectives: To determine the incidence of side effects following treatment of varicose veins with carbon dioxide–oxygen (CO2/O2) foam sclerotherapy, and to compare results with historical controls using CO2- or air-based foams.Design: Cohort study with prospective data collection, private clinic setting.Patients: The patient population consisted of one hundred patients, 95% women, age 52 SD 13 years-old, CEAP class C2EpAsPr.Methods: Patients underwent ultrasound-guided foam sclerotherapy following thermal ablation of saphenous trunks; 1–3% polidocanol and 70%CO2–30%O2 gas were mixed in a 1:4 proportion. Volume injected averaged 22 SD 11 (range: 2–46) mL. Vital signs were monitored for 1 h; side effects were recorded up to 24 h post treatment. Incidence of side effects was compared to CO2- and air-based foam data.Results: Heart rate decreased from 73 SD 11 at the start to 68 SD 9 bpm (p < 0.001, paired t-test) following the procedure. Systolic and diastolic pressures, 127/75 SD 18/14 mmHg, respiratory rate, 15 SD 4 rpm and pO2, 98 SD 2%, did not change significantly. Itching (7) or leg pain (24) reporting was similar to that for air-based foam (p = NS). Lack of reported chest tightness and/or dry cough was superior to our previous data with CO2 or air foam (p < 0.05). Reporting of dizziness (1) was less than that for air-based foam (p = 0.002). The incidence of visual disturbance (2%), was comparable with that for CO2 (3%) or air (8%) foam, but too few cases were available for meaningful statistical analysis.Conclusions: Foam sclerotherapy using CO2/O2 foam was well tolerated by patients and resulted in fewer side effects than similar treatment using air foams.

Unite for Education!

I. Koncar, N. Ilic, M. Dragas, I. Banzic, L. Davidovic — 2010-07-02

I am writing you concerning decreasing experience in open vascular surgery and its’ influence on education, discussed in the last Supplement of European Journal of Vascular and Endovascular surgery.

Comment on “Perioperative blood glucose monitoring and control in major vascular surgery patients”

Jonas Malmstedt, Jesper Swedenborg — 2010-07-12

Our article Influence of perioperative blood glucose levels on outcome after infrainguinal bypass surgery in patients with diabetes, has been cited by Kuijk et al. in the otherwise excellent review on perioperative blood glucose control in major vascular surgery (page 629, citation 18). The findings of our study are however incorrectly cited. The main finding was that “Poor perioperative glycaemic control was associated with unfavourable outcome and local complications after infrainguinal bypass surgery in these diabetic patients.”

Response to comment on: “perioperative blood glucose monitoring and control in major vascular surgery patients”

Jan Peter van Kuijk, Don Poldermans — 2010-07-20

We would like to thank the authors for their comments on our review article. Several studies have reported a high prevalence of diabetes mellitus (DM) in patients undergoing vascular surgery. Dunkelgrun et al. demonstrated that the use of oral glucose tolerance testing, detected DM in 75% of the patients that would have been missed using fasting plasma glucose measurement only. This study emphasized the need for more intensive screening for DM in the high-risk vascular surgery patients. Malmstedt et al. performed a prospective observational study of a small group of diabetic patients scheduled for infrainguinal bypass surgery, and observed that poor perioperative glycaemic control was associated with unfavourable outcome and local complications. From a pathophysiological point of view it is really hard to study the cause–effect relation regarding DM and local complications, like wound infection. On the one hand, the presence of DM in vascular surgery patients increases the risk of perioperative hyperglycaemia with related inflammatory complications. On the other hand, vascular surgery creates an inflammatory response which can be accelerated by dysregulated DM.

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

2010-09-01

A Case of Spontaneous Superficial Femoral Artery Dissection

S. Rajagopalan, A. Geraghty, K. Hallam, J. Brittenden — 2010-06-21

We present a case of acute ischaemia of the lower limb due to a spontaneous dissection of the superficial femoral artery successfully revascularised with an emergency surgical bypass.

Spontaneous Regression of a Limb Arterio-Venous Malformation (AVM) in a Patient with Parkes-Weber Syndrome (PWS)

T. Barlow, A. Egun — 2010-06-24

Klippel Trenauney Syndrome (KTS) consists of the triad of venous and cutaneous capillary malformations, and tissue hypertrophy. The association with an Arterio-Venous Malformation (AVM) is known as Parkes-Weber Syndrome (PWS). We present a case of spontaneous regression of multiple small AVMs in the lower leg of a 19-year-old female with PWS. To the best of our knowledge this is the first documented case of spontaneous regression of an AVM in PWS in English literature.

Two Cases of Mis-diagnosed Popliteal Artery Entrapment Syndrome

C.M. Lamb, C.G. Davies, T. Whitbread — 2010-07-05

We present two young patients with persistent lower leg pains on exercise. Both had previously been investigated and treated with bilateral, 4-compartment fasciotomies for presumed chronic compartment syndrome with no effect on their symptoms. Vascular imaging in both relaxed and resisted plantar-flexed positions revealed a diagnosis of popliteal artery entrapment syndrome (PAES) and both patients underwent bilateral release of the popliteal arteries to curative effect.

EJVES vol. 40, issue 3 (September 2010) - Chinese Translated Abstracts

2010-09-01

EJVES vol. 40 issue 3 (September 2010) - Spanish Translated Abstracts

2010-09-01

Forthcoming events

2010-09-01