European Journal of Vascular & Endovascular Surgery

Editorial Board

2010-02-01

Advanced Carotid Plaque Imaging

L. Hermus, G.M. van Dam, C.J. Zeebregts — 2009-12-23

Abstract: Treatment of carotid artery stenosis by endarterectomy or stenting can significantly reduce stroke risk. In clinical practice, indication for surgery or stenting is primarily based on the degree of stenosis, but there is growing awareness that pathophysiological features within a vulnerable plaque play a key role in predicting stroke risk. Important molecular processes associated with plaque vulnerability are inflammation, lipid accumulation, proteolysis, apoptosis, angiogenesis and thrombosis. The rapidly emerging field of molecular and functional imaging strategies allows identification of pathophysiological processes in carotid artery stenosis.We aimed to review the literature regarding the current most promising advanced imaging techniques in carotid artery disease.Various advanced imaging methods are available, such as high-resolution magnetic resonance imaging (HR-MRI), single photon emission computed tomography (SPECT), positron emission tomography (PET) and near-infrared fluorescence (NIRF). Radionuclide and fluorescent tracers that identify inflammation, apoptosis and proteolysis, such as FDG, MMP probes and Annexin A5, are promising. A combination of activity of molecular processes and detailed anatomic information can be obtained, providing a powerful tool in the identification of the vulnerable plaque. With these developments, we are entering a new era of imaging techniques in the selection of patients for carotid surgery.

Relationship of Carotid Plaque Echomorphology to Presenting Symptom

D.A. Russell, S.M. Wijeyaratne, M.J. Gough — 2009-11-25

Abstract: Background: Attempts to stratify carotid plaques according to clinical risk using single longitudinal view (SLV) echomorphology have not been uniformly successful. We compared SLV grey scale median measurements (SLV-GSM) with a newer technique of multiple cross-sectional view echomorphology (MCSV-GSM) in carotid plaques from 3 patient groups (asymptomatic, ocular, and hemispheric symptoms).Methods: SLV and MCSV images were obtained from 109 carotid stenoses (70–99%; 41 hemispheric, 17 ocular, 51 asymptomatic). SLV-GSM and MCSV-GSMmin (lowest plaque MCSV image GSM) were determined to assess echolucency whilst MCSV-GSMmax−min (highest minus lowest MCSV-GSM) assessed heterogeneity.Results: Echolucency was greater (lower GSM) in plaques causing hemispheric symptoms versus asymptomatic plaques (MCSV-GSMmin, P = .002; SLV-GSM, P = .002). Only MCSV imaging detected differences in echolucency between asymptomatic plaques and those causing ocular symptoms (SLV-GSM, p = 0.84; MCSV-GSMmin, p = .003). Symptomatic plaques showed greater heterogeneity versus asymptomatic plaques, significantly in those causing ocular symptoms (hemispheric P = .126; AF P = .011).Conclusions: Both SLV and MCSV echomorphology confirm increased echolucency in plaques causing hemispheric symptoms. Plaques causing ocular symptoms could only be distinguished from asymptomatic plaques with MCSV assessment (increased echolucency and heterogeneity). This suggests that amaurosis fugax may be associated with a more focal plaque instability that is best detected with MCSV imaging.

Systematic Preoperative Coronary Angiography and Stenting Improves Postoperative Results of Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease: A Randomised Controlled Trial

2009-12-14

Abstract: Objective: To evaluate the usefulness of systematic coronary angiography followed, if needed, by coronary artery angioplasty (percutaneous coronary intervention (PCI)) on the incidence of cardiac ischaemic events after carotid endarterectomy (CEA) in patients without evidence of coronary artery disease (CAD).Materials and methods: From January 2005 to December 2008, 426 patients, candidates for CEA, with no history of CAD and with normal cardiac ultrasound and electrocardiography (ECG), were randomised into two groups. In group A (n=216) all the patients had coronary angiography performed before CEA. In group B, all the patients had CEA without previous coronary angiography. In group A, 66 patients presenting significant coronary artery lesions at angiography received PCI before CEA. They subsequently underwent surgery under aspirin (100mgday−1) and clopidogrel (75mgday−1). CEA was performed within a median delay of 4 days after PCI (range: 1–8 days).Risk factors, indications for CEA and surgical techniques were comparable in both groups (p>0.05). The primary combined endpoint of the study was the incidence of postoperative myocardial ischaemic events combined with the incidence of complications of coronary angiography. Secondary endpoints were death and stroke rates after CEA and incidence of cervical haematoma.Results: Postoperative mortality was 0% in group A and 0.9% in group B (p=0.24). One postoperative stroke (0.5%) occurred in group A, and two (0.9%) in group B (p=0.62). No postoperative myocardial event was observed in group A, whereas nine ischaemic events were observed in group B, including one fatal myocardial infarction (p=0.01). Binary logistic regression analysis demonstrated that preoperative coronary angiography was the only independent variable that predicted the occurrence of postoperative coronary ischaemia after CEA. The odds ratio for coronary angiography (group A) indicated that when holding all other variables constant, a patient having preoperative coronary angiography before carotid surgery was 4 times less likely to have a cardiac ischaemic event after carotid surgery. No complications related to coronary angiography were observed and no cervical haematomas occurred in patients undergoing surgery under aspirin and clopidogrel in this study.Conclusions: Systematic preoperative coronary angiography, possibly followed by PCI, significantly reduces the incidence of postoperative myocardial events after CEA in patients without clinical evidence of CAD.

Clinical Results of Carotid Denervation by Adventitial Stripping in Carotid Sinus Syndrome

R.J. Toorop, M.R. Scheltinga, M.C. Huige, F.L. Moll — 2009-10-14

Abstract: Aims: Older patients with spells of syncope may suffer from a carotid sinus syndrome (CSS). Patients with invalidating CSS routinely receive pacemaker treatment. This study evaluated the safety and early outcome of a surgical technique termed carotid denervation by adventitial stripping for CSS treatment.Methods: Carotid sinus massage (CSM) during cardiovascular monitoring confirmed CSS in patients with a history of repeated syncope and dizziness. The internal carotid artery was surgically denervated by adventitial stripping over a minimum distance of 3cm via a standard open approach. Patient characteristics, perioperative complications and 30-day success rate were analyzed.Results: A total of 39 carotid denervation procedures was performed in 27 individuals (23 males, mean age 70±3 years) between 1980 and 2007 in a single institution. Eleven patients had a bilateral hypersensitive carotid sinus. Procedure related complications included wound hematoma (n=4), neuropraxia of the marginal mandibular branch of the facial nerve (n=2) and dysrhythmia responding to conservative treatment (n=3). Significant alterations in systolic and diastolic blood pressure and heart rate were not observed. One patient developed a cerebral ischaemic vascular accident on the 24th postoperative day. One patient with residual disease had a successful redenervation within 1 month after the initial operation. Two patients with persistent symptoms received a pacemaker but also to no avail. At 30-day follow up 25 of 27 patients (93%) were free of syncope, and 24 free of a pacemaker (89%).Conclusion: Carotid denervation by adventitial stripping of the proximal carotid internal artery is effective and safe and may offer a valid alternative for pacemaker treatment in patients with carotid sinus syndrome.

Carotid Denervation by Adventitial Stripping: A Promising Treatment of Carotid Sinus Syndrome?

P. Kolh — 2009-12-07

The baroreflex is an important component of the physiological short-term control of the blood pressure. Baroreceptors are mainly located in the wall of the aortic arch and of the internal carotid artery (ICA). The carotid sinus nerve (CSN) contains afferent fibres travelling from the carotid sinus' baroreceptors located in the adventitia of the ICA. It joins the glossopharyngeal (IX) nerve and ends in the nucleus tractus solitarius in the brain stem. The efferent loop is conducted by the vagus (X) nerve to the heart leading to a physiologic bradycardia and inhibited atrio-ventricular conduction, in response to systemic hypertension. Also, a blocked sympathetic nerve system causes venodilatation, decreasing ventricular preload, and vasodilatation, both leading to decreased blood pressure.

An Analysis of 50 Surgically Managed Penetrating Subclavian Artery Injuries

S. Sobnach, A.J. Nicol, H. Nathire, S. Edu, D. Kahn, P.H. Navsaria — 2009-11-12

Abstract: Objectives: The surgical management and outcome of penetrating subclavian artery (SCA) injuries is presented in this article.Design: A retrospective chart review is used to detail the management and outcome of penetrating SCA injuries.Patients and methods: Patients with penetrating SCA injuries presenting to the Groote Schuur Hospital from January 1997 to December 2007 were reviewed. Demographic data, mechanism of injury, associated injuries, angiographic findings, surgical treatment, hospital stay, complications and mortality were noted.Results: Fifty patients with penetrating SCA injuries were identified from an operating trauma database. Stab and gunshot wounds accounted for 40 and 10 SCA injuries, respectively. The mean Revised Trauma Score (RTS) was 7.2. Angiography was obtained in 37 patients; false aneurysm (13) and total occlusion (nine) were the two most common findings. A median sternotomy was required in 25 (50%) patients and emergency room thoracotomy was performed in two patients (4%) for initial haemorrhage control. Primary repair of SCA injuries was possible in 52% of the patients. Three SCA injuries (6%) were ligated and one patient received an endovascular stent. Morbidity was restricted to associated brachial plexus injuries. The limb salvage rate was 100% and there were no deaths.Conclusion: Preoperative angiography was useful in planning an operative approach. Primary repair was possible in the majority of the patients and ligation of SCA injuries was life-saving in critically ill patients.

Repair of Arterial Injury after Blunt Trauma in the Upper Extremity – Immediate and Long-term Outcome

J. Klocker, J. Falkensammer, L. Pellegrini, M. Biebl, T. Tauscher, G. Fraedrich — 2009-12-08

Abstract: Objective: In contrast to upper extremity stab and gunshot wounds, data on management and outcome in blunt trauma (BT) are limited by small numbers and short follow-up periods.Methods: This study is a retrospective data analysis. All patients who had undergone arterial repair after upper-limb BT were included. Exclusion criteria were artery ligation and/or primary limb amputation. Endpoints included the following: peri-operative death, limb salvage, primary and secondary patency, vascular re-operation and/or intervention.Results: Eighty-nine patients (71 male; median age: 34.6 years, range: 2.5–81.7) underwent reconstruction of 96 arteries after BT since 1989: subclavian (n=16), axillary (n=22), brachial (n=48) and forearm (n=10). Concomitant arm vein lesions were present in 15 patients (17%) and accompanying nerve (n=38; 43%) and/or orthopaedic injuries (n=64; 72%) in 77 patients (87%). The 30-day mortality rate was 2% with the limb-salvage rate being 98%. Six reconstructions occluded during the first week (primary/secondary patency rate: 93%/99%). After a median follow-up time of 5.1 years, 67% of the patients were followed: There were no secondary amputations and no arterial re-interventions.Conclusions: Arterial repair in upper extremity BT has excellent early and long-term outcome. In contrast to a significant risk of early occlusion, limb loss after repair, late vascular re-intervention and late arterial occlusion or stenosis are rare.

Bypass Surgery for the Treatment of Upper Limb Chronic Ischaemia

2009-11-12

Abstract: Objectives: This study aims to evaluate the results and complications of surgical arterial revascularisation of the upper limb for treatment of chronic ischaemia using infrabrachial bypass. Results of limb salvage and follow-up with graft patency are analysed.Design: This study is a retrospective analysis of 23 patients affected by chronic upper limb ischaemia and treated by surgical bypass.Materials and methods: We retrospectively analysed 23 patients with upper limb ischaemia treated between January 1998 and January 2008, by means of bypass graft revascularisation. After surgical revascularisation, eight patients (35%) with digital gangrene underwent minor amputations during the same surgical session, or within the following few days. Postoperatively, patients were followed up at regular intervals of 1, 3 and 6months, and every 6months thereafter, both clinically and with a duplex ultrasound scan.Results: The mean 34months’ follow-up was 96% complete. Life table analysis revealed a primary patency of 82.6% and secondary patency of 91.3%. Limb salvage was 100%.During the follow-up period, four patients sustained graft occlusion and, of these, two underwent re-do revascularisation with success.Conclusions: We believe upper limb bypass surgery represents a valid treatment in this clinical setting, both for limb salvage and for relief of symptoms.

Endovascular Repair of Thoracoabdominal Aortic Aneurysms

2009-11-30

Abstract: Objectives: To evaluate the early outcomes following thoracoabdominal aortic aneurysm (TAAA) repair utilising fenestrated and branched endografts.Design and materials and methods: A prospective analysis of all patients undergoing endovascular repair of TAAA in a single academic centre. All patients were deemed unfit for open surgical repair. Customised endografts were designed using CT data reconstructed on 3D workstations. Post-operatively all patients were evaluated radiologically at hospital discharge, at 6, 12, 18 and 24months, and annually thereafter.Results: Thirty-three consecutive patients (30 males) were treated over 33months (August 2006 to April 2009). Median age and aneurysm size were 70years (range 50–83years) and 64mm (range 55–100mm) respectively. 114/116 (98%) of the targeted visceral vessels were successfully catheterised and perfused. The in-hospital mortality rate was 9% (3/33). Transient spinal cord ischaemia was diagnosed in 4/33 (12%) patients, and permanent paraplegia in one (3%). The median follow-up period was 11months (range 1–33months). Endoleaks were identified in 5/33 (15%) patients: type II in four patients and a type III endoleak in one patient which required the only secondary intervention. During follow-up, two patients died: one from stroke and the other from myocardial infarction 9 and 29months respectively after the procedure.Conclusion: This preliminary study, which includes our learning curve, confirms the feasibility and safety of the endovascular repair of TAAA in high-risk patients. Meticulous follow-up to assess sac behaviour and visceral perfusion is critical in order to ensure optimal results of these complex endovascular repairs requiring numerous mating components.

Spinal Cord Injury is Not Negligible after TEVAR for Lower Descending Aorta

2009-12-04

Abstract: Objectives: To clarify the incidence of spinal cord injury (SCI) after thoracic endovascular aneurysm repair (TEVAR), we investigate the intercostal/lumbar arteries that supply the Adamkiewicz artery (ICA-AKA).Patients: Among 81 patients subjected to TEVAR, we retrospectively reviewed the clinical records of 50 patients (range: 57–86 (median age: 77) years, 41 males) who underwent TEVAR for part of or the whole distal descending aorta (T7 to L2) after identification of ICA-AKA by magnetic resonance angiography (MRA) or computed tomography angiography (CTA).Results: The 50 patients were classified into group A: 17 patients whose patent ICA-AKA was not covered, group B: 24 patients whose ICA-AKA was covered and group C: nine patients in whom no patent ICA-AKA was identified. Only three patients in group B suffered paraplegia and of them two recovered full ambulation. The estimated incidence of permanent and transient paraplegia was 3.7% in all TEVAR patients, 6.0% when part of or the entire distal aorta was covered and 12.5% when the patent ICA-AKA was covered. The length of aortic coverage in patients with paraplegia was >300mm.Conclusions: Paraplegia after TEVAR occurred in one of eight patients in whom the stent graft covered ICA-AKA. Long coverage of the aorta including the ICA-AKA was critical. To prevent this serious complication, identification of the ICA-AKA is crucial.

The Proximal Fixation Strength of Modern EVAR Grafts in a Short Aneurysm Neck. An In Vitro Study

2009-11-25

Abstract: Objectives: The study aims to measure the strength of the proximal fixation of endografts in short and long necks.Design: Three types of endografts were compared: Gore Excluder®, Vascutek Anaconda® and Medtronic Endurant®.Materials and methods: The proximal part of the stent grafts was inserted in bovine arteries and the graft was then attached to a tensile testing machine. The force to obtain dislodgement (DF) from the aorta was recorded for each graft at proximal seal lengths of 10 and 15mm.Results: The median DF (interquartile range, IQR) for the Excluder, the Anaconda and the Endurant with a seal length of 15mm was: 11.8 (10.5–12.0) N, 20.8 (18.0–30.1) N and 10.7 (10.4–11.3) N. With the shorter proximal seal of 10mm, DF was, respectively: 6.0 (4.5–6.6) N, 17.0 (11.2–36.6) N and 6.4 (6.1–12.0) N.Conclusions: The proximal fixation of the Anaconda is superior to the Excluder and the Endurant at short necks of 10 and 15mm in an experimental set-up. There is a statistically significant decrease of proximal fixation for the Excluder stent graft, when decreasing the length of the proximal neck from 15 to 10mm.

The Influence of Different Types of Stent Grafts on Aneurysm Neck Dynamics after Endovascular Aneurysm Repair

2009-11-02

Abstract: Objective: Dynamic imaging provides insight into aortic shape changes throughout the cardiac cycle. These changes may be important for proximal aortic stent graft fixation, sealing and durability. The objective of this study is to analyse the influence of different types of stent grafts on dynamic changes of the aneurysm neck.Methods: Pre- and postoperative electrocardiography (ECG)-gated computed tomographic angiography (CTA) scans were obtained in 30 abdominal aortic aneurysm (AAA) patients, 10 each from three different types of stent grafts (10 Talent, Endurant, and Excluder). Each dynamic CTA dataset consisted of eight reconstructed images over the cardiac cycle. Aortic area and radius changes during the cardiac cycle were determined at two levels: (A) 3 cm above and (B) 1 cm below the lowermost renal artery. Radius changes were measured over 360 axes, and plotted in a polar plot. An ellipse was fitted over the plots to determine radius changes over the major and minor axis for assessment of the asymmetric aspect and most prominent direction of distension.Results: Baseline characteristics did not differ significantly between the three groups. Preoperatively, the aortic area increased significantly (p < 0.001) over the cardiac cycle in all patients at both levels: (A) mean increase 8.3 ± 4.1% (2.0–17.3%); (B) mean increase 5.9 ± 4.2% (1.9–12.4%). The postoperative aortic area increase over the cardiac cycle did not differ significantly from preoperative increases: (A) mean increase 9.9 ± 2.2% (4.4–20.0%); (B) mean increase 7.7 ± 2.4% (3.8–12.4%). The difference between radius change over the major and minor axis was significant both pre- and postoperatively for all three stent grafts, indicating asymmetric distension. Suprarenal, the distension showed a tendency to right-anterior and infrarenal to left-anterior. The distension and direction of the aortic expansion was preserved after stent grafting. There were no differences between the three types of stent grafts regarding their impact on the aortic distension or direction of this distension.Conclusion: The aorta expands significantly and asymmetrically throughout the cardiac cycle. After implantation of abdominal aortic stent grafts, the aortic distension and direction of distension remain equally preserved in all three groups. The three stent graft types studied seem to be able to adapt to the asymmetric dynamic aortic shape changes.

Diabetes and the Abdominal Aortic Aneurysm

S. Shantikumar, R. Ajjan, K.E. Porter, D.J.A. Scott — 2009-11-30

Abstract: Objective: The aim of this review is to delineate the association between abdominal aortic aneurysms (AAAs) and diabetes mellitus. Mechanisms for the underlying association are then discussed.Methods: A systematic review of the English-language literature using PubMed, EMBASE and Cochrane databases was undertaken up to September 2009. Studies reporting appropriate prevalence data were identified and a meta-analysis performed.Results: Eleven studies were identified. The prevalence of diabetes mellitus in studied patients with AAA ranged from 6% to 14%. The prevalence of diabetes in control patients without AAA ranged from 17% to 36%. Pooled analysis suggested a reduced rate of diabetes amongst people with AAA compared to those without (OR 0.65, 0.60–0.70, p<0.001).Conclusions: Studies so far suggest a protective role for diabetes on the development of AAA. Further research is required to demarcate the underlying mechanisms for this possible association.

Screening for Abdominal Aortic Aneurysm among Patients Referred to the Vascular Laboratory is Cost-effective

K. Mani, M. Ålund, M. Björck, J. Lundkvist, A. Wanhainen — 2009-11-27

Abstract: Screening for abdominal aortic aneurysm (AAA) in high-risk groups has been recommended based on a high prevalence of disease, while being questioned due to a high frequency of co-morbidities and inferior life-expectancy. We evaluated the long-term outcome and the cost-effectiveness of selective AAA screening among patients referred to the vascular laboratory for arterial examination.Methods: A total of 5924 patients, referred to the vascular laboratory of a university hospital, were screened for AAA with ultrasound (definition: ∅≥30mm), 1993–2005. Outcome data were gathered through hospital records and the national population registry. A Markov model was used for health–economic evaluation.Results: An AAA was detected in 181 patients (mean age 72.8 years), of whom 21.5% underwent elective repair (perioperative mortality 5.1%) after 7.5 years of follow-up. Four of six patients diagnosed with AAA rupture were operated upon. Relative 5-year survival compared with the general Swedish population, controlled for age and sex, was 80.4% (95% confidence interval (CI): 70.8–88.8). The cost-effectiveness was robust in base-case (11 084 Euro/life year gained) and in sensitivity analyses of prevalence, cost and survival.Conclusions: Patients in whom AAA was detected at selective screening had inferior long-term survival and were operated on less frequently, compared with AAA patients described in previous studies. Yet, selective screening at the vascular laboratory was cost-effective.

Primary Aortoenteric Fistula Due to a Swallowed Twig in a Three-year-old Child

S.K. Kappadath, M.J. Clarke, E. Stormer, L. Steven, B. Jaffray — 2009-11-25

Abstract: Aortoenteric fistulae are infrequent causes of gastrointestinal bleeding and usually occur as a late complication of aortic aneurysm repair. Primary aortoenteric fistulae are very rare and most have an aetiological association with atherosclerotic aneurysmal disease.We report a primary aortoenteric fistula (PAEF) occurring in a 3 year old as a result of duodenal perforation after ingestion of a twig. To our knowledge this is the first case of a primary aortoenteric fistula reported in a child. Emergency aortic surgery in children needs certain considerations which are briefly discussed.

Poor Inter-observer Agreement on the TASC II Classification of Femoropopliteal Lesions

2009-12-03

Abstract: Objectives: This study aims to evaluate the reproducibility of femoropopliteal TASC II classification and to analyse the influence of an educational intervention on inter-observer agreement.Design: This is a validation study.Materials: This study included 200 consecutive angiograms of femoropopliteal arterial lesions.Methods: Seven investigators evaluated the first 100 angiograms, independently aided by the available TASC guide. Thereafter, the intervention included a discussion of the 25 most problematic cases, initially by a panel of 22 vascular surgeons, and later by the seven investigators to clarify grading principles. In the second stage, the 100 remaining cases were evaluated independently. A multi-rater variation of Brennan and Prediger's free-marginal kappa (κfree) was used to calculate inter-observer agreement.Results: There were lesions not fitting any of the TASC classes. Total agreement among all seven investigators was reached in 7% and 19% of the cases before and after the intervention, respectively. In the first stage, κfree was 0.32 between all observers (range between two observers κfree=0.11–0.54). The intervention increased the agreement to κfree=0.49 (range: 0.20–0.56). Agreement between the two observers was 38–69% (mean 49%) before the intervention and 51–73% (mean 61%) thereafter.Conclusions: TASC II classification for femoropopliteal lesions allows individual interpretations, and the common use of this classification as a basis for decision making and reporting outcomes could therefore be questioned.

Advantages and Limitations of TASC II Classification of Femoropopliteal Lesions

J.-B. Ricco — 2010-01-20

In this issue of the Journal, T. Kukkonen et al. evaluate the reproducibility of femoropopliteal TASC II classification by reviewing 200 angiograms of patients having femoropopliteal occlusive arterial lesions. Seven investigators evaluated the first 100 angiograms with the help of the TASC II guide followed by a debate of the 25 most difficult cases with a panel of 22 vascular surgeons. After the debate, the seven investigators reviewed the 100 remaining cases independently.

Modified Ankle–brachial Index Detects More Patients at Risk in a Finnish Primary Health Care

2009-12-07

Abstract: Objectives: Despite peripheral arterial disease (PAD), defined as ankle–brachial index (ABI)≤0.9, being an independent predictor of cardiovascular morbidity and mortality, it is rarely used in the primary care. Various definitions for PAD (i.e., ABI≤0.9 or ABI≤0.95) exist. In addition, a modified ABI (ABImod) using the lowest ankle pressure improves identification of patients at risk. The prevalence of PAD in primary care and association of different ABI calculations with atherosclerotic disease burden is not known.Design: The research was conducted as a prospective cross-sectional study. Finnish health centres and 99 general practitioners were selected and trained for ABI measurement. Consecutive patients were recruited using inclusion criteria: age 50–69 years and one or more cardiovascular risk factors or age ≥70 years or calf pain during exercise. A total of 817 patients were recruited.Methods: Research methods included interview and Doppler measurement of brachial and ankle pressures.Results: An ABImod≤0.9 yielded the highest prevalence of PAD (47.7%), had the best sensitivity and identified the highest number of patients with coronary artery disease (CAD), cerebrovascular disease (CVD), PAD, CAD/CVD/PAD and polyvascular disease (PVD) at the cost of reduced specificity. All ABI calculations were independently associated with atherosclerotic disease burden. Interestingly, ABI≥1.4 had the strongest association with CVD.Conclusions: PAD is highly prevalent among patients presenting to primary care. ABImod calculation detects more number of patients at risk at the cost of reduced specificity. The association of high ABI with CVD noted in this study warrants future research for validation.

Excimer Laser Ablation in the Treatment of Total Chronic Obstructions in Critical Limb Ischaemia in Diabetic Patients. Sustained Efficacy of Plaque Recanalisation in Mid-term Results

2009-11-25

Abstract: This prospective study aims to evaluate the impact of the excimer laser technology as the first-line endovascular treatment of critical limb ischaemia (CLI) in diabetic patients. The protocol allowed the use of laser ablation of obstructive lesions when conventional endoluminal guidewire crossing of the plaque was unsuccessful. We extrapolate the data of consecutive patients treated, who completed at least 12 months of follow-up, extending the observation to a 26-month time frame. During this period, 67 diabetic patients with CLI were brought to the Cath Lab for ‘operative angioplasty’ and to be treated with endovascular techniques. Of the 67 cases, laser was used on 35 patients to treat 51 lesions. All patients had type C or D occlusive lesions, according to the TACS II classification, showing a single type D plaque or multiple tandem C/D occlusive plaques ranging from 4 to 23cm in length. The immediate clinical success, defined as restored direct arterial flow to the foot, was 88.2%. The lesions were successfully crossed by laser in 45 out of 51 attempts. Stents were required in 25% of the patients with 21% lesions. Patency rates were assessed using the Kaplan–Meier survival curves. The patency rates of the successfully treated lesions (freedom from target lesion revascularisation) were 96.6% at 12 months and 82.7% at 24 months. Limb-salvage rate at 12 and 24 months were 100% and 94%, respectively. Our study showed that the excimer laser-assisted angioplasty, when feasible, is effective in granting event-free survival in CLI patients with diabetes, and that endoluminal-driven atherectomy allows long-term success in reducing the need of stents in the lower limb arteries.

Conversion During Laparoscopic Aortobifemoral Bypass: A Failure?

2009-11-05

Abstract: Objectives: To study the impact of conversion on postoperative recovery, morbidity and mortality in laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease (AIOD).Design: Retrospective analysis of a prospectively maintained database.Methods: Between November 2002 and December 2006, 139 patients were treated for severe AIOD with a laparoscopic aortobifemoral bypass at one community and one university hospital. Demographic data, operative data, postoperative recovery data, morbidity and mortality were recorded and analysed according to a conversion and a non-conversion group.Results: Conversion was needed in 13.7% of the patients. Morbidity was 16.5%–14.2% in the non-conversion group and 31.8% in the conversion group. Systemic morbidity was significantly higher in the conversion group (31.6% vs.10%; p=0.002), but only one patient had incomplete recovery; local morbidity was comparable in both groups (10.5% vs. 5.8%; p=0.337). Mortality rate was 2.2%.Conclusion: Laparoscopic aortobifemoral bypass surgery is a safe procedure for the treatment of AIOD. The outcome of patients after conversion is not affected in the way that it could be an impediment to start a laparoscopic procedure. Conversion in time is a safe way to overcome the learning curve.

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

2010-02-01

Endoluminal Repair of a Contained Thoracic Aortic Rupture Due to Primary Staphylococcal Aortitis

I. Töpel, F. Audebert, G. Herzog, M.G. Steinbauer — 2009-10-30

We report a case of primary infectious thoracic aortitis with contained rupture of the descending thoracic aorta caused by Staphylococcus aureus and successfully treated with a rifampicin-rinsed aortic stent graft.

“Bill's Bulge” – a 14.5cm Femoral Aneurysm Case Report and Literature Review

T.A. Mirza, A. Karthikesalingam, S. Chetcuti, A. Winterbottom, K. Varty — 2010-01-21

Introduction: True femoral aneurysms are a rare but important cause of groin swelling. Report: We report a 79 year-old male, presenting with intermittent claudication and leg oedema after 25 years of a growing left groin swelling. On examination the mass was 14.5cm in diameter and pulsatile with an audible bruit. Distal pulses were absent. Perfusion was restored by interposition of a PTFE graft between CFA and PFA.

Aneurysm of the Coeliacomesenteric Trunk: A Rare Anomaly

Y. Iida, Y. Obitsu, H. Komai, H. Shigematsu — 2009-11-16

A coeliacomesenteric trunk (CMT) aneurysm is extremely uncommon in splanchnic aneurysm, accounting for less than 0.5% of the population. We report a case of CMT aneurysm that led to surgical treatment. The patient underwent excision of the aneurysm with successful vascular reconstruction. Only eight cases of CMT aneurysm have been reported so far. Awareness of congenital vascular anomalies and grasp of embryologic development are necessary for adequate surgical intervention.

Combined Endovascular and Surgical Treatment in Takayasu's Arteritis-Induced Renal Artery Stenosis (TARAS) Complicated with Vein–Graft Aneurysm of the Aorto-Renal By-pass

K. Papazoglou, K. Konstantinidis, I. Genios — 2009-12-14

Introduction: We report a case of combined endovascular and surgical treatment in a patient with Takayasu's arteritis-induced bilateral renal artery occlusion. Report: A 38-year-old women suffering from Takayasu's arteritis-induced renal artery stenosis (TARAS) was referred to our centre. The patient also complained of claudication and of symptoms related to ostial stenosis of superior mesenteric artery. She was treated with a sequence of open and endovascular procedures and is now on a 3-year uneventful follow-up.

Forthcoming Events

2010-02-01

European Society for Vascular Surgery: Past President of European Society dies

2010-02-01