European Journal of Vascular & Endovascular Surgery - Articles in Press

Ultrasound-Guided Sclerotherapy of the Great Saphenous Vein with 1% vs. 3% Polidocanol Foam: A Multicentre Double-Blind Randomised Trial with 3-Year Follow-Up - Corrected Proof

S. Blaise, J.L. Bosson, J.M. Diamand — 2010-03-08

Abstract: Objectives: The aim of this study was to compare the efficacy and side effects of ultrasound-guided foam sclerotherapy of the great saphenous vein using 1% and 3% polidocanol foam with a 3-year follow-up.Design: A multicentre prospective double-blind randomised clinical trial comparing the efficacy of 1% vs. 3% polidocanol sclerosant foam.Materials and methods: Patients with incompetence of the great saphenous vein (GSV) in CEAP clinical classes C2–5 (CEAP, Clinical–Etiology–Anatomy–Pathophysiology), with or without incompetence of the sapheno-femoral junction, were included. The Turbofoam® method was used to create 1% and 3% polidocanol foam, which was injected into the GSV under ultrasound guidance, with a volume not exceeding 10 ml. Further foam sclerotherapy was carried out at 6 weeks, 3 and 6 months if required to abolish persistent venous reflux. The main outcome measure was the absence of saphenous reflux as assessed by ultrasound imaging at 6 months, 1, 2 and 3 years. Clinical severity (Venous Clinical Severity score (VCSS)) and quality of life (the Chronic Venous Insufficiency Questionnaire (CIVIQ)) scores were assessed.Results: A total of 143 patients were included; 1% group men = 18, women = 55, 3% group men = 19, women = 51. The abolition of venous reflux was: 1% group, 69% and 3% group, 85% at 6 months; 1% group, 79% and 3% group, 78% at 3 years (including additional injections at 6 months). Three asymptomatic thrombo-embolic events (2%) occurred. Local side effects (principally pigmentation and matting) were 9% in the 3% group and 6% in the 1% group at 3 years (N.S.). Clinical severity and quality of life scores improved by more than 20% at 6 months in both the groups, with no difference between the groups.Conclusions: This is the first randomised clinical trial of ultrasound-guided foam sclerotherapy which is a 3-year follow-up and shows equivalent efficacy of 1% and 3% sclerosant foam.Clinical trial registration number: 2006-07-05.

Below-the-ankle Angioplasty is a Feasible and Effective Intervention for Critical leg ischaemia - Corrected Proof

M.F. Abdelhamid, R.S.M. Davies, S. Rai, J.D. Hopkins, M.J. Duddy, R.K. Vohra — 2010-03-08

Abstract: Aim: Occlusion or severe stenosis of pedal and plantar arteries limits surgical options for critical limb ischaemia (CLI). Below-the-ankle (BTA) angioplasty is potentially useful as an adjunct to proximal angioplasty. In this study, the feasibility and outcome of this procedure were explored, as they have not been evaluated previously.Methods: Patients' demographics, indications, procedures and outcomes were recorded. Outcomes were determined by technical success, primary patency, limb salvage and amputation-free survival (AFS) rates.Results: Between 2004 and 2008, 42 cases of BTA angioplasty were performed for 39 patients. Forty cases (95.2%) had CLI. Technical success was achieved in 88% of cases. At 6, 12 and 24 months, AFS was 70.7%, 60.9% and 57.1%, limb salvage was 84.9%, 81.9% and 81.9% and patient survival was 83.3%, 73.8% and 67.3, respectively. Seven major amputations (16.6%) were performed, four of which had failed angioplasty. Two patients required re-intervention. Univariate analysis showed insulin-dependent diabetics, occlusive lesions, failure of angioplasty and state of the run off to be the predictors of limb loss.Conclusions: BTA angioplasty for pedal and plantar arterial occlusive disease is technically feasible. It has good medium-term clinical outcome and limb salvage in a group of patients with poor surgical options.

Endovascular Stent Graft Management of a Ruptured Profunda Femoris Artery Aneurysm - Corrected Proof

S. Saha, V. Trompetas, B. Al-Robaie, H. Anderson — 2010-03-08

Introduction: We report the first case of a ruptured profunda femoris artery (PFA) aneurysm managed successfully with an endovascular stent graft. Report: An 87-year-old man presented with pain and pulsatile swelling on his thigh from a ruptured large saccular aneurysm arising from the mid PFA. The aneurysm was successfully excluded with an endovascular stent graft. The patient made a good recovery post procedure.

Fenestrated Stent Grafting for Short-necked and Juxtarenal Abdominal Aortic Aneurysm: An 8-Year Single-centre Experience - Corrected Proof

2010-03-04

Abstract: Objectives: To present an 8-year clinical experience in the endovascular treatment of short-necked and juxtarenal abdominal aortic aneurysm (AAA) with fenestrated stent grafts.Methods: At our tertiary referral centre, all patients treated with fenestrated and branched stent grafts have been enrolled in an investigational device protocol database. Patients with short-necked or juxtarenal AAA managed with fenestrated endovascular aneurysm repair (F-EVAR) between November 2001 and April 2009 were retrospectively reviewed. Patients treated at other hospitals under the supervision of the main author were excluded from the study. Patients treated for suprarenal or thoraco-abdominal aneurysms were also excluded. All stent grafts used were customised based on the Zenith system. Indications for repair, operative and postoperative mortality and morbidity were evaluated. Differences between groups were determined using analysis of variance with P < 0.05 considered significant.Results: One hundred patients (87 males/13 females) with a median age of 73 years (range, 50–91 years) were treated during the study period; this included 16 patients after previous open surgery or EVAR. Thirty-day mortality was 1%. Intra-operative conversion to open repair was needed in one patient. Operative visceral vessel perfusion rate was 98.9% (272/275). Median follow-up was 24 months (range, 1–87 months). Twenty-two patients died during follow-up, all aneurysm unrelated. No aneurysm ruptured. Estimated survival rates at 1, 2 and 5 years were 90.3 ± 3.1%, 84.4 ± 4.0% and 58.5 ± 8.1%, respectively. Cumulative visceral branch patency was 93.3 ± 1.9% at 5 years. Visceral artery stent occlusions all occurred within the first 2 postoperative years. Four renal artery stent fractures were observed, of which three were associated with occlusion. Twenty-five patients had an increase of serum creatinine of more than 30%; two of them required dialysis. In general, mean aneurysm sac size decreased significantly during follow-up (P < 0.05).Conclusions: Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm appears safe and effective on the longer term. Renal function deterioration, however, is a major concern.

Salvage Treatment for Venous Aneurysm Complicating Vascular Access Arteriovenous Fistula: Use of an Exoprosthesis to Reinforce the Vein after Aneurysmorrhaphy - Corrected Proof

2010-03-04

Abstract: Objectives: We report a new salvage technique for treating venous aneurysms (VAs) complicating vascular access arteriovenous fistula (AVF) using externally reinforced venous aneurysmorrhaphy.Design: A retrospective study over a 20-month period from a single centre.Patients: Patients presenting to the vascular surgery department, Bordeaux University Hospital for revision of a vascular access AVF were included.Methods: Reinforced venous aneurysmorraphy consisted in removal of redundant vessel wall followed by reinforcement using an external prosthetic graft. Patency, diameter and flow were assessed by duplex ultrasound at 1, 6 and 12 months after salvage.Results: Thirty-eight eligible patients were identified. Five were excluded because VA was associated with central vein stenosis; the remaining 33 underwent salvage. Indications were rapidly expanding or painful VA in seven cases; VA with frequent bleeding or damaged overlying skin in eight; VA in close relation to a stenosis in two; and VA associated with high-flow rate in 16. Cannulation was attempted after 30 days. Mean follow-up time was 12 S.D. 5 months (range: 4–22). Two repaired AVFs failed. Primary 1-year patency was 93%. No aneurysm or infection occurred. Reduction of high flow was successful in 12 of 16 patients. The remaining four required re-operation.Conclusions: Reinforced venous aneurysmorrhaphy is effective in controlling venous dilation and achieving patency. Reduction of high-flow rates was not always achieved. Further study is needed to evaluate long-term efficacy of this treatment.

Oestradiol Levels in Varicose Vein Blood of Patients with and without Pelvic Vein Incompetence (PVI): Diagnostic Implications - Corrected Proof

G. Asciutto, A. Mumme, K.C. Asciutto, B. Geier — 2010-03-04

Abstract: Purpose: To assess the difference in the oestradiol levels of blood taken from varicose veins in patients with and without pelvic vein incompetence (PVI).Materials and methods: Women of child-bearing age with symptomatic primary or recurrent varicose veins of the great saphenous vein (GSV) were included in a prospective study. Patients underwent duplex ultrasonography and pelvic vein phlebography. They were divided into a group with PVI (PVI group) and a control group with GSV reflux alone (VV group). Blood samples were collected from the GSV at the sapheno-femoral junction or lower in the thigh as well as from the arm. Oestradiol levels were determined by electroluminescence.Results: Between January and December 2007, 40 women were studied, of which 19 showed phlebographic evidence of PVI (PVI group), while 21 were included in the VV group. Phlebography revealed an incompetent ovarian vein in 14 (74%) patients of the PVI group, dilated uterine and ovarian plexuses in 12 (63%) and an incompetent internal iliac vein in six cases (32%). In the PVI group, the median oestradiol level in GSV samples was 121pgml−1 (range: 12–4300), while in the VV group the median level was 75pgml−1 (range: 9–1177). In the upper limb, the PVI group patients had a median level of 78pgml−1 (range: 15–121) and the VV group patients 68pgml−1 (range: 13–568). The ratio of lower limb/upper extremity was significantly higher (p<0.002) in patients of PVI group (median: 1.9; range: 0.7–33) than in those of the VV group (median: 1.1; range: 0.8–13). A threshold ratio of 1.4 showed the highest combined sensitivity and specificity in differentiating patients with PVI from those without.Conclusions: In patients with varicose veins arising from the GSV, oestradiol levels were significantly higher in the lower limb than in the upper extremity in the subgroup with associated PVI. It may be possible to use this observation as a diagnostic test in patients with suspected PVI. This deserves further study.

Management of HIV Vasculopathy – A South African Experience - Corrected Proof

J.V. Robbs, N. Paruk — 2010-03-02

Abstract: The aim of the study was to describe the presentation management and short term results of therapy (< 1 month) in patients admitted with HIV vasculopathy.Records were culled from a prospectively maintained data base on the Vascular Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa between January 2005 and June 2009.226 patients were studied; 111 had aneurysms and 115 occlusive disease. 98% were African and ages ranged from 4–53 years (average 36); 90% were male. The CD4 count ranged from 1–930 cells/mm3 while serum albumin averaged 30 mMol/L.202 aneurysm presented in 111 participants; commonest sites were superficial femoral artery (40%) and carotid (25%). 82 patients had standard operative repair and 8 had stent grafts; 29 were not treated due to advanced disease.Within 30 days of operation the mortality was 9% with 5% developing graft sepsis and 11% pulmonary complications.Of 115 with occlusive disease, there were 2 distinct groups. 51 had no previous claudication and had acute thrombosis; no thrombophilia could be demonstrated. 64 had premature atherosclerotic disease. The majority presented with critical ischaemia.In the acute thrombosis group 15 (29%) had primary amputation, limb salvage was achieved in 13 (36%) and 4 died (11%). In the chronic occlusive group 30 (47%) had primary amputation, of 25 submitted to surgery limb salvage was achieved in 17 (68%).Low CD4 count and albumen levels did not correlate with mortality or complications.Conclusion: Surgical therapy for aneurysm is worthwhile in the short term.Following occlusive disease there is a 25% overall salvage rate in the short term (< 1/12) but the long term outlook is uncertain.

Response to ‘Magnetic Resonance Imaging for Aortic Dissection’ - Corrected Proof

2010-03-02

We read with great interest the commentary by RE Clough, T Schaeffter and PR Taylor about the importance of MRA in aortic dissections. Nevertheless, controversy concerning the superiority of multidetector computed tomography (MD-CT) versus MRI still exists.

CT Angiography Followed by Endovascular Intervention for Acute Superior Mesenteric Artery Occlusion does not Increase Risk of Contrast-Induced Renal Failure - Corrected Proof

S. Acosta, S. Björnsson, O. Ekberg, T. Resch — 2010-03-02

Abstract: Objectives: Acute superior mesenteric artery (SMA) occlusion can be diagnosed in an early phase by computed tomography (CT) angiography, which is also a prerequisite for endovascular intervention. However, the issue of development of postoperative permanent renal failure due to contrast-induced nephropathy has not been evaluated.Design: RetrospectiveMaterials: A total of 55 patients with acute SMA occlusion were retrieved from the in-hospital register during a 4-year period between 2005 and 2009.Methods: Glomerular filtration rate was calculated as a simplified variant of Modification of Diet in Renal Disease Study Group (MDRD).Results: Preoperative renal insufficiency was found in 52%; advanced state in one patient. Creatinine was lower (p = 0.018) at discharge (median: 71 μmol L–1), compared to admission (median: 76 μmol L–1), in the 32 survivors exposed to repeated iodinated contrast media (median: 54.7 g iodine). No patient died due to renal failure or needed dialysis after endovascular intervention. Endovascular intervention was associated with a higher survival rate (p = 0.001).Conclusion: Serious acute contrast-induced nephropathy was not found in patients diagnosed by CT angiography and treated by endovascular procedures for acute SMA occlusion. Elevated serum creatinine levels should not deter the clinician from ordering a CT angiography in patients with suspicion of acute SMA occlusion.

Abdominal Aortic Doppler Waveform in Patients with Aorto-iliac Disease - Corrected Proof

G. Styczynski, C. Szmigielski, J. Leszczynski, A. Kuch-Wocial, M. Szulc — 2010-03-02

Abstract: Objectives: The mid-systolic deceleration (notch) in the proximal descending aortic Doppler waveform was reported to be common in patients with aorto-iliac disease. However, evaluation of the descending aorta is limited to echocardiography and may be technically difficult. Therefore, we decided to check whether similar Doppler flow disturbance can be found in abdominal aorta, which is easily evaluated in wider range of patients undergoing general abdominal and vascular ultrasound, as well as echocardiography.Methods: We evaluated 115 consecutive symptomatic patients with severe peripheral artery disease admitted for vascular surgery, and 60 controls. The presence or absence of the mid-systolic deceleration in the Doppler waveform was evaluated retrospectively, by the single echocardiographer blinded to the localisation of the arterial occlusion or stenosis.Results: The mid-systolic notch in the proximal abdominal aorta was present in 58 of 71 patients (82%) with significant aorto-iliac disease, seven of 44 (16%) patients with occlusion or significant stenosis distally to the external iliac artery (P < 0.001) and in none of the patients from the control group. Sensitivity, specificity and positive predictive value of the mid-systolic notch in the abdominal aortic Doppler waveform in the detection of aorto-iliac disease in patients with peripheral artery disease were 82%, 84% and 89%, respectively.Conclusion: The mid-systolic deceleration (notch) in the proximal abdominal Doppler waveform is a simple ultrasonographic marker of significant aorto-iliac disease.

Catheter-delivered Transducer-tipped Ultrasound Thrombolysis of a Chronically Occluded Aortic Stentgraft Limb - Corrected Proof

2010-02-26

Endovascular aneurysm repair (EVAR) is increasingly used to treat infrarenal abdominal aortic aneurysm. EVAR is almost exclusively accomplished by using bifurcated, bi-iliac stentgrafts. Nevertheless, it is accompanied with a considerable incidence of stentgraft limb occlusion. In case of acute occlusion endovascular revascularization options are plentiful, but for chronically occluded stentgraft limbs such consensus is lacking. Catheter-delivered transducer-tipped ultrasound (US) thrombolysis is a new technique specifically coined for the treatment of (sub)acute peripheral arterial occlusions and deep venous thrombosis. We describe a unique case of successful treatment of a chronically occluded stentgraft limb after EVAR with catheter-delivered transducer-tipped US thrombolysis.

Occlusion of the Profunda Femoris Artery in Competitive Cyclists - Corrected Proof

A. Mathew, T. Fysh, J.R. Bottomley, J.F. Thompson, J.D. Beard — 2010-02-26

Symptomatic lower limb ischaemia in endurance athletes and competitive cyclists is usually due to iliac artery compression syndrome. We report the cases of two competitive cyclists who presented with thigh claudication, with no previous cardiovascular or thrombo-embolic risk factors. They both had normal conventional and sports exercise tests. Further investigations revealed flush occlusion of the profunda femoris artery, believed to be due to dissection. Both patients improved with graduated exercise. We recommend contrast-enhanced MRA as the investigation of choice for this previously unreported condition.

Immunomodulation of Vascular Diseases: Atherosclerosis and Autoimmunity - Corrected Proof

G-P. Shi — 2010-02-26

Abstract: The autoimmune disease atherosclerosis contributes to several vascular complications. Besides vascular cells, inflammatory cells occur prominently in atherosclerotic lesions; lymphocytes play a detrimental role in the initiation and progression of this common vascular disease. Recent discoveries have led to the identification of several important lymphocyte types within the atherosclerotic lesions. However, peripheral lymphocytes and those in the lymphoid organs both figure critically in the regulation of atherosclerotic lesion growth. Although the concept of atherosclerosis as an autoimmune disease is well known, the ways in which autoantigens and autoantibodies contribute to atherogenesis in human or even in animal models remains largely unknown. For example, autoantigen immunisation can either promote or attenuate atherogenesis in animals, depending on the antigen types and the routes and carriers of immunisation. This article summarises recent findings regarding lesion inflammatory cell types, autoantigens and autoantibody isotypes that can affect the initiation and progression of atherosclerosis from both human and animal studies.

Percutaneous Access for Endovascular Aneurysm Repair: A Systematic Review - Corrected Proof

A.H. Malkawi, R.J. Hinchliffe, P.J. Holt, I.M. Loftus, M.M. Thompson — 2010-02-25

Abstract: Introduction: Recent developments in aortic stent-graft technology have led to an increase in the use of wholly percutaneous endovascular aneurysm repair (P-EVAR). The literature was systematically reviewed to analyse the results of P-EVAR.Methods: A systematic review of P-EVAR was performed using Ovid-MEDLINE in-process and other nonindexed citations and Ovid-MEDLINE and EMBASE (January 1991–July 2009). Primary outcomes reviewed were success rate and loco-regional complications. Secondary outcomes included; operative time, hospital stay, time to ambulation, blood loss and cost. Prospective randomised and controlled nonrandomised studies were included as were case series (retrospective and prospective). Case reports, letters, review articles and non-English language articles were excluded.Results: Twenty-two papers were identified. These included randomised trials (n=1); prospective nonrandomised (n=10) and retrospective studies (n=11). P-EVAR was attempted in 1087 patients (1751 groins). Overall success rate of percutaneous arterial closure was 92% (90.1–93.9, 95% CI). Access related complication rate was 4.4% (3.5–5.3, 95% CI). Seven studies provided data on access related complications in open access cohorts (O-EVAR). In these studies, P-EVAR was associated with fewer access related complications (RR 0 .47, 95% CI 0.28–0.78, p=0.004). P-EVAR was associated with reduced operative time.Conclusion: P-EVAR appears safe and effective in selected patients. Local access related complications were low. Further work is required to identify the most suitable candidates for P-EVAR.

Impact of Long-term Corticosteroid Therapy on the Distribution Pattern of Lower Limb Atherosclerosis - Corrected Proof

2010-02-22

Abstract: Objective: Ectopic calcification and mediacalcinosis can be promoted by corticosteroid use. Aim of the present investigation is to describe macrovascular disease features in patients with long-term corticosteroid therapy and symptomatic lower limb peripheral arterial occlusive disease (PAD).Methods: A consecutive series of 2783 patients undergoing clinical and angiographic work-up of PAD were screened for long-term (>5 years) corticosteroid use (group A). Comparison was performed to a randomly selected age-, sex- and risk factor-matched PAD control cohort from the same series without corticosteroid use (group B). Patients with diabetes mellitus or severe renal failure were excluded. Arterial calcification was evaluated by qualitative assessment on radiographic images. Severity of atherosclerotic lesions was analysed from angiographic images using a semi-quantitative score (Bollinger score).Results: In general, 12 patients (5 males, mean age 78.5 ± 9.0 years) with 15 ischaemic limbs qualified to be enrolled in group A and were compared to 23 matching control patients (6 2males, mean age 79.5 ± 6 years) with 32 ischaemic limbs. Incompressibility of ankle arteries determined by measurement of the ankle-brachial index was seen in 12 limbs (80%) in group A compared to 3 limbs (9%) in group B (p = 0.0009). No significant difference was found comparing group A and B for segmental calcification, whereas comparison of the atherosclerotic burden using the angiographic severity score showed a significantly higher score at the infragenicular arterial level in group A (p = 0.001).Conclusion: Findings suggest that the long-term corticosteroid therapy is associated with a distally accentuated, calcifying peripheral atherosclerosis inducing arterial incompressibility. This occlusion pattern is comparable to patients with renal failure or diabetes. Further research is required to support our observations.

Interobserver Agreement of the TASC II Classification for Supra- and Infrainguinal Lesions - Corrected Proof

A. Zimmermann, H. Wendorff, T. Schuster, F. Auer, H. Berger, H.-H. Eckstein — 2010-02-22

Abstract: Objectives: The Trans-Atlantic Inter-Society Document on Management of Peripheral Arterial Disease (TASC) gives treatment recommendations depending on the classification of aorto-iliacal or femoro-popliteal vascular pathologies. Therefore, the best treatment could only be offered if the right TASC classification was obtained. The purpose of this study was to assess the interobserver agreement of the evaluation of the TASC II classification for peripheral arterial occlusive disease (PAOD) in magnetic resonance angiography (MRA).Patients and methods: Three hundred arterial segments of 149 patients with a magnetic MRA for PAOD were evaluated according to the TASC II classification. A resident and a consultant for radiology and vascular surgery both performed independent grading. A comparative assessment of the consensus agreement was quantified by the marginal probabilities calculated by generalised estimation equation models, as well as by using the weighted kappa coefficient (κ), classified according to Altman.Results: In relation to the consensus, the overall agreement was good to excellent for the consultants of radiology and vascular surgery. The consultants obtained a statistically significant higher agreement than did the residents (Odds ratio (OR): 2.86, 95% confidence interval (CI): 2.21–3.69, p<0.001). A significantly higher consensus agreement probability was observed for the surgeons compared with the radiologists (OR: 1.43, 95% CI: 1.11–1.84, p=0.006) and for the femoro-popliteal regions compared with the aorto-iliacal regions (OR: 1.64, 95% CI: 1.12–2.14, p=0.012).Conclusion: Although good results can be achieved in the assessment of vascular lesions according to the TASC II document, a simplification of this classification could increase its practicability in a daily clinical routine.

Basilic Vein Transposition: What is the Optimal Technique? - Corrected Proof

S.K. Kakkos, G.K. Haddad, M.R. Weaver, R.K. Haddad, M.M. Scully — 2010-02-22

Abstract: Objectives: To compare the outcome of the one-stage basilic vein transposition (BVT) fistula with a modified, two-stage technique.Design: Retrospective case-controlled study, performed in an academic centre.Material: A total of 173 candidates for BVT fistula (87 males, mean age 61 years).Methods: In one-stage BVT, the basilic vein is mobilised through a single incision, placed inside an anterolateral arm tunnel and anastomosed with the brachial artery. In two-stage procedures, the fistula–arterial anastomosis is created first, followed by the second stage, after fistula maturation several weeks later, when the basilic vein is mobilised through two skip incisions, transected near the anastomosis, placed inside an anterolateral arm tunnel and reanastomosed. Morbidity and fistula maturation rate were the main outcome measures.Results: In one-stage BVT (n=76), the incidence of venous hypertension, wound haematomas and all complications (17%, 13% and 43%, respectively) was significantly higher than in two-stage procedures (n=98) (4%, p=0.004, 3%, p=0.012 and 11%, p<0.001, respectively). Time (68 days) to fistula use was significantly decreased in one-stage BVT than in two-stage procedures (132 days, p<0.001) but failure to mature rate was equivalent (15% vs. 18%, p=0.49).Conclusions: Our results indicate that the two-stage BVT fistula through two skip-arm incisions is superior to the established one-stage procedure in terms of less morbidity but at the cost of a second operation and longer time to access use. Further research comparing these two techniques is necessary. Until this issue is resolved, an individualised approach is suggested.

Magnetic Resonance Imaging for Aortic Dissection - Corrected Proof

R.E. Clough, T. Schaeffter, P.R. Taylor — 2010-02-22

We would like to congratulate the authors on their review of imaging for thoracic aortic disease. However, we would like to comment on the section regarding dissection. Multidetector contrast-enhanced computed tomography (CT) remains the most widely available modality for imaging patients with this disease, but has some limitations which may be misleading. The images acquired are a representation of one moment in the cardiac cycle and these static images may not illustrate the complex anatomical and functional changes occurring in aortic dissection. The dimensions of the true and false aortic lumens will vary with systole and diastole and this will have an effect on factors such as device sizing and determining dynamic from static obstruction. Magnetic resonance imaging (MRI) with ECG-gating is able to give static and dynamic high-resolution information in a single examination.

Maintained Geometry, Elasticity and Contractility of Human Saphenous Vein Segments Stored in a Complex Tissue Culture Medium - Corrected Proof

G.F. Molnár, A. Nemes, V. Kékesi, E. Monos, G.L. Nádasy — 2010-02-22

Abstract: Objective: Improved maintenance of endothelial function and higher viability of saphenous vein grafts stored in a complex tissue culture medium (TCM) have been demonstrated. This article studies the biomechanical properties of saphenous vein segments.Design: Biomechanical properties of 72 saphenous vein segments remaining from coronary bypass grafting of 32 patients have been studied after different storage procedures.Materials: The materials studied included fresh segments, segments stored in a cooled conventional physiological salt solution (normal Krebs–Ringer (nKR)) for 1–2 weeks, segments stored in a cooled chemically defined TCM (X-Vivo) for 1,2,3 and 4 weeks and segments cryopreserved for a few weeks.Methods: Specimens were cannulated at both ends and pressure–diameter curves were recorded in the 0–85-mmHg range in nKR with 10μM norepinephrine added to induce maximum smooth muscle contraction, as well as in Ca2+-free medium to induce full relaxation. Tensile strength was checked at 300mmHg. Distensibility, elastic modulus and active strain were computed.Results: Segments stored in nKR dilated morphologically, their distensibility decreased and they lost their ability to contract (1.5±0.7% from 10.1±1.5% of control) in 1 week. The TCM-stored segments preserved their contractility until 1 week, and this parameter only slowly decreased afterwards (first week, 11.5±7.3%; fourth week, 3.9±0.6%). There was a slight decrease in wall thickness but the lumen diameter was not affected. The elastic parameters of these segments were practically identical to those of fresh segments. Cryopreserved segments narrowed morphologically, their wall thickened and contractility diminished.Conclusions: Storage in TCM helps preserve the passive and active biomechanical properties of human saphenous vein segments. Such properties can be expected to improve graft tissue viability.

Unrecognized Basilic Vein Variation Leading to Complication during Basilic Vein Transposition Arteriovenous Fistula Creation: Case Report and Implications for Access Planning - Corrected Proof

C.L. Kaiser, J.E. Anaya-Ayala, N. Ismail, M.G. Davies, E.K. Peden — 2010-02-22

Abstract: Introduction: Knowledge about variations of the venous arm anatomy is limited despite its importance for a successful arteriovenous fistula creation.Report: We describe a complication of a Basilic Vein Transposition (BVT) resulting from failure to recognize aberrant anatomy. The brachial–basilic junction was located in an unusual position near the antecubital fossa leading to inadvertent distal brachial vein ligation and transposition of basilic and the proximal and unusually unpaired brachial vein.Discussion: This case highlights the prevalence of anomalies of upper extremity veins and the need for thorough Duplex vein mapping before surgery for the preservation and planning of future access.

Short Leukocyte Telomere Length is Associated with Abdominal Aortic Aneurysm (AAA) - Corrected Proof

G. Atturu, S. Brouilette, N.J. Samani, N.J.M. London, R.D. Sayers, M.J. Bown — 2010-02-22

Abstract: Objective: Telomeres are specialised DNA structures present at the ends of linear chromosomes, which shorten with each successive cell division and the length of which represents cellular biological age. The aim of this study was to determine the relationship between abdominal aortic aneurysm (AAA) and white cell telomere length.Methods: Peripheral blood samples were collected from 190 patients with AAA and 183 controls. Genomic DNA was extracted from white cells and telomere lengths determined using a chemiluminescence technique.Results: The mean white cell telomere length was significantly lower in AAA patients compared to controls (median age 66 years in both groups), with a mean difference of 189 base pairs (bp) (95% confidence interval 77bp to 301bp, P=0.005). This relationship between case–control status and mean telomere restriction fragment (TRF) length did not change after adding other risk factors into a multiple regression model. The risk of having AAA doubled in patients with a mean TRF length in the lowest quartile compared to patients with a mean TRF length in the highest quartile (odds ratio 2.30, 95% Confidence Interval 1.28–4.13, P=0.005).Conclusion: Our data show that patients with AAA have shorter leukocyte telomere length compared to controls. This suggests that vascular biological aging may have a role in the pathogenesis of AAA.

Fenestrated Stent Grafting for Aortic Aneurysm in Europe - Corrected Proof

J.-B. Ricco — 2010-02-22

In this issue of the journal, Amiot et al. and Verhoeven et al. presented their experience of fenestrated stent grafting for short-necked and juxta-renal abdominal aortic aneurysms.

Primary Lymphoedema and Lymphatic Malformation: Are they the Two Sides of the Same Coin? - Corrected Proof

B.B. Lee, J.L. Villavicencio — 2010-02-22

Abstract: Objectives: To clear the confusion regarding the relationship between the ‘primary lymphoedema’ and (truncular) lymphatic malformation (LM); the latter is one of congenital vascular malformations.Materials & Methods: A literature review was carried out on the primary lymphoedema either existing as an independent LM lesion or as a component of the Klippel–Trenaunay syndrome.Results: The review was able to provide a contemporary guide/conclusion on the definition and classification, clinical evaluation and clinical management regarding conservative (physical) therapy, reconstructive surgical therapy and ablative/excisional surgical therapy, for the primary lymphoedema as an LM.Conclusions: Primary lymphoedema can be considered as ‘congenital’ since its majority represents a clinical manifestation of the truncular type of LM arising during the later stages of lymphangiogenesis. Such embryological staging information of the LM is critical for proper management of the primary lymphoedema when it exists with other congenital vascular malformations (Klippel–Trenaunay syndrome).2. Basic non-invasive to minimally invasive tests will provide an adequate diagnosis and lead to the correct multidisciplinary, specifically targeted and sequenced treatment strategy.3. The mainstay of current management of the primary lymphoedema/truncular LM is complex decongestive therapy; and the reconstructive as well as ablative surgical therapy remain adjunctive therapies at best.

Hybrid Repair of an Aberrant Right Subclavian Artery with Kommerell's Diverticulum - Corrected Proof

P. Tosenovsky, F. Quigley, J. Golledge — 2010-02-22

This publication describes a hybrid endovascular and open surgical approach to treating a large aneurysm of an aberrant right subclavian artery (Kommerell's diverticulum). A 76-year old man presented with dysphagia lusoria due to a 3.5 x 3.0cm aneurysm involving an aberrant right subclavian artery. The patient was treated by a thoracic aortic endograft, left subclavian artery de-branching (by its transposition to the left common carotid artery) and right subclavian artery revascularisation. This approach avoids the requirement for a thoracotomy or sternotomy needed with open surgical repair. At a 6 months follow-up assessment the aneurysm was shown to be thrombosed with no evidence of endoleak.

Time of Flight Magnetic Resonance Angiography: A Trap for the Unwary - Corrected Proof

L. Corfield, A. Speirs, D.J. McCormack, M. Waltham — 2010-02-22

Introduction: Magnetic resonance imaging is now frequently used to image blood vessels. This case illustrates a pitfall of this mode of imaging. Report: A 6-year-old girl sustained a severe neck injury and subsequently developed a Horner's syndrome. A time-of-flight magnetic resonance scan could be interpreted by the inexperienced as showing an extensive dissection. However, a contrast-enhanced scan confirmed the presence of a localised carotid injury only.

Comments regarding ‘Duplex Ultrasound and Contrast-Enhanced Ultrasound Versus Computed Tomography for the Detection of Endoleak after EVAR’ - Corrected Proof

P. De Rango — 2010-02-18

In this issue of the Journal, Mirza et al. identified that Contrast-enhanced Ultrasound (CEUS) may provide a sensitive (0.98%) and accurate tool to investigate endoleak after endovascular aortic repair (EVAR), while traditional Unenhanced Ultrasound (USS) is unreliable because of poor sensitivity (0.77%).

Predictive Risk Factors for Restenosis after Remote Superficial Femoral Artery Endarterectomy - Corrected Proof

2010-02-18

Abstract: Objectives: Restenosis following remote superficial femoral artery endarterectomy (RSFAE) remains a challenging problem. The determinants predicting failure are lacking. This study investigated patient characteristics with predictive value for restenosis during the first year after RSFAE.Design: A prospective cohort study.Materials and methods: A total of 90 patients post-RSFAE were studied for the occurrence of restenosis “(peak systolic velocity ratio ≥ 2.5)” in the first 12 months postoperatively. At baseline, clinical parameters were recorded. Vessel size was measured on the basis of plaque perimeter in the culprit lesion and lumen diameter on perioperative digital subtraction angiography.Results: In 57 patients (63%), a restenotic lesion was diagnosed within 12 months following surgery. Patients with longer time interval between start of ischaemic walking complaints and RSFAE revealed a significantly higher incidence of restenosis (hazard ratio (HR) = 1.3 (1.05–1.52) per 4 years). Small plaque perimeter and small superficial femoral artery (SFA) diameter on angiography were significantly associated with restenosis (HR = 0.54 (0.34–0.88) per 10 mm and HR = 0.46 (0.27–0.78) per 1.5 mm, respectively). In multivariate analysis, age, duration of ischaemic walking complaints and lumen diameter were independently associated with increased risk of restenosis after RSFAE.Conclusions: This study provides evidence that age, vessel size and duration of ischaemic walking complaints before RSFAE are predictive values for restenosis after RSFAE.

Comment on “Patients Undergoing Cardiac Surgery with Asymptomatic Unilateral Carotid Stenoses have a Low Risk of Perioperative Stroke” - Corrected Proof

R. Borioni, R. De Paulis, F. Tomai, M. Garofalo — 2010-02-18

Although we have appreciated the meaningful paper of Baiou et al., we are not fully convinced to exclude every asymptomatic patient from combined carotid endarterectomy (CEA) and cardiac procedures, particularly in candidates to coronary artery bypass grafting (CABG). We have to consider that a significative number of candidates to CABG may present cerebrovascular threatening carotid lesions, even if they have no previous symptoms. In a study on 68 patients who underwent simultaneous CEA and CABG we reported an unstable or ulcerated carotid plaques in 23 out of 42 asymptomatic patients (54.7%). Moreover, in our current clinical practice we observe many vulnerable carotid plaques (ulceration, intra-plaque hemorrhage with or without rupture of the intima) on CEA + CABG patients, which resulted mostly asymptomatic.

Response to comment on “Patients undergoing cardiac surgery with asymptomatic unilateral carotid stenoses have a low risk of perioperative stroke” - Corrected Proof

A.R. Naylor — 2010-02-18

Thank you for your comments regarding our study which concluded that patients with unilateral, asymptomatic carotid stenoses undergoing coronary artery bypass grafting (CABG) have a low risk of stroke. You propose that CABG patients require routine evaluation of plaque morphology and that prophylactic carotid interventions should be offered to those with ‘vulnerable’ plaques. However, unless I am mistaken, no-one has conclusively shown that asymptomatic ‘vulnerable’ plaques pose any greater risk of procedural stroke during cardiac surgery.

Clinical Outcome of Acute Leg Ischaemia Due to Thrombosed Popliteal Artery Aneurysm: Systematic Review of 895 Cases - Corrected Proof

R.H.J. Kropman, A.M. Schrijver, J.C. Kelder, F.L. Moll, J.P.P.M. de Vries — 2010-02-15

Abstract: Objectives: A systematic review was performed to summarise outcomes of acute thrombosed popliteal artery aneurysms (PAAs) treated with thrombolysis or thrombectomy followed by bypass.Methods: A systematic review was conducted of data on acute thrombosed PAAs dated 1 January 1990 through 30 June 2008 using the Cochrane Library, MEDLINE and EMBASE databases. Primary endpoint was limb salvage; secondary endpoints were mortality and patency of the bypasses.Results: Eight prospective studies and 25 retrospective studies with 895 patients presenting with acute ischaemia were included. No randomised trials were included. The mortality rate after surgical repair was 3.2% (95% confidence interval (C.I.) 1.8–4.6). The amputation rate was 14.1% (95% C.I. 11.8–16.4). Thrombolysis before surgery did not result in a significant reduction of the number of amputations, compared with surgery (thrombectomy and bypass) alone. The mean primary patency rates of the bypasses at 1, 3 and 5 years were 79%, 77% and 74%, respectively, in the ‘thrombolysis’ group and 71% (P=0.026), 54% (P=0.164) and 45% (P=0.249) in the ‘thrombectomy’ group. No distinction could be made regarding secondary patency and limb-salvage rates between the groups owing to insufficient data.Conclusions: Preoperative and intra-operative thrombolyses result in a significant improvement in 1-year primary graft patency rates, but do not result in a significant reduction for amputations compared with surgery alone.

Stem Cell Therapy in PAD - Corrected Proof

R.W. Sprengers, F.L. Moll, M.C. Verhaar — 2010-02-15

Abstract: Critical limb ischemia (CLI) continues to form a substantial burden on Western health care. Despite recent advances in surgical and radiological vascular techniques, a large number of patients is not eligible for these revascularisation procedures and faces amputation as their ultimate treatment option. Growth factor therapy and stem cell therapy – both therapies focussing on augmenting postnatal neovascularisation – have raised much interest in the past decade. Based on initial pre-clinical and clinical results, both therapies appear to be promising strategies to augment neovascularisation and to reduce symptoms and possibly prevent amputation in CLI patients. However, the underlying mechanisms of postnatal neovascularisation are still incompletely understood. Both fundamental research as well as large randomised trials are needed for further optimisation of these treatment options, and will hopefully lead to needed advances in the treatment of no-option CLI patients in the near future.

Proper Selection of Patients for Percutaneous Embolo-Sclerotherapy in Patients with Congenital Vascular Malformations (CVMs) - Corrected Proof

Y.-W. Kim — 2010-02-15

Abstract: For the treatment of congenital vascular malformation (CVM), conservative, endovascular and/or surgical treatment have been sporadically attempted according to the type, location and clinical manifestations of the vascular lesions. At current practice, with no established treatment guidelines for CVM patients, there is much room for ineffective interventions and occurrence of complications related with the treatment.Therefore, it is important to select proper candidates for the endovascular or surgical treatment in CVM patients to avoid ineffective treatment and its complications and to obtain better treatment results.We describe the basic considerations before the selection of candidates for percutaneous embolo-sclerotherapy in patients with CVM based on our own experiences at a specialised CVM clinic.

Cryoplasty of the Venous Anastomosis for Prevention of Intimal Hyperplasia in a Validated Porcine Arteriovenous Graft Model - Corrected Proof

2010-02-15

Abstract: Objectives: Cryoplasty combines conventional angioplasty – percutaneous transluminal angioplasty (PTA) – with cold thermal energy. In this animal study, we investigated if preventive cryoplasty could reduce intimal hyperplasia (IH) at the venous anastomosis.Design: We investigated cryoplasty versus PTA of the venous anastomosis in a validated porcine, bilateral, arteriovenous graft model.Animals and methods: In 12 pigs, 24 expanded polytetrafluoroethylene (ePTFE) grafts were bilaterally inserted between the common carotid artery and internal jugular vein. Directly after surgery, one venous anastomosis was treated with cryoplasty at −10°C, the contralateral anastomosis with conventional PTA. At 4 weeks, graft flow was measured, quantitative angiography was performed and grafts with adjacent vessels were excised for histological analysis.Results: Due to a number of thromboses, data for paired analysis were available from eight pigs. Angiographic outflow vein diameter and graft blood flow were not different between treatment groups. Compared with the control group, IH at the venous anastomosis was reduced by 47% (P=0.21) and intima/media ratio was reduced by 45% (P=0.07) by cryoplasty. Effects were most profound in those animals that tended to develop most IH.Conclusion: Our results suggest that preventive cryoplasty of the venous anastomosis might help to reduce IH in those cases that develop most profound IH.

In Memoriam Professor Dr. André Nevelsteen - Corrected Proof

P. Peeters, R. Verhelst — 2010-02-15

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

The Education System to Master Endovascular Aortic Repair in Japan – The Japanese Committee for Stentgraft Management - Corrected Proof

Y. Obitsu, S. Ishimaru, H. Shigematsu — 2010-02-12

Abstract: Objective: The Japanese Committee for Stentgraft Management (JACSM) was established with the aim of ensuring the safe and proper reach of commercial stent grafts following their regulatory approval. This study examines the validity of the practice standards developed by JACSM.Methods: JACSM comprises 10 associations related to endovascular treatment. Based on the practice standards developed by JACSM, the status of practising institutions, practising surgeons, supervising surgeons and the results of follow-up surveys were analysed.Results: In the 2.5 years following the establishment of JACSM, 298 institutions have fulfilled the practice standards. The number of practising surgeons reached 493, and the number of supervising surgeons reached 177. There were 3089 registered cases up to June 2009. The present study analysed 1570 cases registered in the 2 years from July 2006 to June 2008. The hospital mortality rate was low (0.4%) in the follow-up surveys.Conclusions: Early results following the introduction of stent grafts were generally good. The procedure spread safely without the learning curve seen in the initial stages following introduction of new medical materials, indicating that the practice standards were appropriate.

Dysglycaemia in Vascular Surgery Patients - Corrected Proof

M. Astor, E. Søfteland, A. Daryapeyma, T. Jonung — 2010-02-11

Abstract: Oral glucose tolerance tests (OGTTs) have detected a pathologic glucose metabolism in up to 60% of patients with acute coronary syndromes. Only one-third of these were previously diagnosed.The purpose of this study was to determine the prevalence of abnormal glucose metabolism among vascular surgery patients.Methods: Between October 2006 and September 2007, 465 consecutive patients admitted to the vascular surgery unit were asked to participate in the study; however, 121 declined. Among the patients included, 68 had previously known diabetes. A total of 276 patients performed an oral glucose tolerance test (OGTT). We categorised the findings based on fasting and 2-h plasma glucose levels into four groups: diabetes mellitus, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and normal glucose metabolism. Information regarding the affected vascular bed and relevant medical history was also registered.Results: Of the 276 patients who underwent OGTT, 66 (24%) had IGT, 23 (8%) had IFG and 33 (12%) had diabetes. As many as 17 of the 33 patients with newly diagnosed diabetes would have fulfilled the criteria for diagnosis based only on their fasting glucose levels. Including the patients with previously known diabetes, the prevalence of dysglycaemia was 55% and that of diabetes 29%.Conclusions: Total prevalence of dysglycaemia in vascular surgery patients corresponds well to that of acute coronary syndromes. The prevalence of unknown pathological glucose metabolism was 44% in our OGTT material. The use of fasting glucose as the sole diagnostic tool for diabetes would have resulted in the correct diagnosis in only half of the patients tested. OGTT should be considered as a routine investigation in non-diabetic vascular surgery patients. It remains to be seen whether early diagnosis and treatment of dysglycaemia in this patient group will influence the surgical treatment and outcome.

Comment On: “A 15-Year Experience with Combined Vascular Reconstruction and Free Flap Transfer for Limb-Salvage”, C. Randon, B. Jacobs, F. De Ryck, K. Van Landuyt, F. Vermassen Eur. J Vasc Endovasc. Surg 2009;38(3):338–345 - Corrected Proof

M. Lepantalo, M. Kallio, E. Tukiainen — 2010-02-05

Randon et al. recently published the long-term Belgian experience in combining bypass grafting and microvascular free tissue transfer to revascularise severely ischaemic feet with large tissue defects with poor healing potential. We share the joy from their results, but not necessarily from the way our results were used as comparison. Our patients did not have less diabetes, smaller lesions nor poorer results. Most of the patients had diabetes in both series, 70.5% in their, and 73% in our series, not 25%, which was the proportion of the type I diabetic patients.

Letter to Editor - Corrected Proof

K.H. Yow, A. Mahmood, C. Marshall, D. Higman, C.H.E. Imray — 2010-02-03

Your timely survey emphasised the use of oral antiplatelet agents in the perioperative period of carotid endarterectomy (CEA). There is a growing realization of the important role of transcranial Doppler and intravenous antiplatelet therapy in the control of platelet microemboli and associated perioperative strokes. Pre-operatively, recurrent and frequent symptoms may be due to superimposed platelet thrombus in unstable carotid plaque, analogous to the acute coronary syndrome. Indeed, IV Dextrans have been used to reduce the microembolic load, control symptoms and to allow timely progress to CEA on the next elective list.

Anastomotic Pseudoaneurysm Complicating Renal Transplantation: Treatment Options - Corrected Proof

2010-02-01

Abstract: Introduction: Anastomotic pseudoaneurysm following renal transplantation is uncommon. Indications for repair, treatment options and outcomes remain controversial.Report: We present 6 renal transplant recipients with large anastomotic pseudoaneurysms. Five of the patients underwent open repair while one had a stent-grafting and delayed transplant nephrectomy for a ruptured pseudoaneurysm. A transplant nephrectomy was needed in all cases but one. Arterial reconstruction enabled limb salvage in all cases. One patient died of sepsis postoperatively. No patient presented late infection, failure of vascular reconstruction, nor pseudoaneurysm recurrence.Conclusions: Surgical excision of anastomotic pseudoaneurysms results in high rates of allograft loss. Less invasive techniques have a place in selected cases.

A Comparative Study of Carotid Atherosclerotic Plaque Microvessel Density and Angiogenic Growth Factor Expression in Symptomatic Versus Asymptomatic Patients - Corrected Proof

2010-02-01

Abstract: Objective: A challenge facing clinicians is identifying patients with asymptomatic carotid disease at risk of plaque instability. We hypothesise that locally released angiogenic growth factors contribute to plaque instability.Methods: Carotid endarterectomy specimens from eight symptomatic and eight asymptomatic patients were interrogated for microvessel density and angiogenic growth factor expression histologically using immunofluorescence, and biochemically using quantitative real-time polymerase chain reaction (q-RT-PCR). Bio-Plex™ suspension array was used to assess circulating biomarkers in venous blood from the same patients and six healthy age-matched controls.Results: Immunofluorescence demonstrated significantly greater neovessel density in symptomatic plaques (P=0.010) with elevated expression of hepatocyte growth factor (HGF) (P=0.001) and its receptor MET (P=0.011) than in asymptomatic plaques. The q-RT-PCR demonstrated up-regulation of Endoglin (CD105), HGF (P=0.001) and MET (P=0.011) in the plaques of symptomatic versus asymptomatic patients. Bio-Plex™ suspension array demonstrated elevated HGF (P=0.002) serum levels in symptomatic versus asymptomatic patients and healthy controls, and decreased platelet-derived growth factor (PDGF) (P=0.036) serum levels in symptomatic versus asymptomatic patients.Conclusion: Plaque instability may be mediated by HGF-induced formation of new microvessels, and decreased vessel stability resulting from decreased PDGF. Suspension array technology has the potential to identify circulating biomarkers that correlate with plaque rupture risk.

Commentary for ‘The Infwence of Wall Stress on AAA Growth and Biomarkers’ - Corrected Proof

J.P. Archie — 2010-02-01

This is a complex study of 37 patients with abdominal aortic aneurysms that range from 40 to 55 mm in diameter, sizes that are normally followed closely and considered for intervention at the upper end of the diameter range. The authors examined the relationship between maximum aneurysm diameter (Dm), maximum aneurysm wall stress (Sm), aneurysm diameter growth rate and several circulating biomarkers of inflammation and/or degeneration. While Dm is the accepted AAA variable for size classification and management recommendations, the advent of computational methods for determining local wall stresses from CT scans has emerged in the past decade as a potentially powerful tool for predicting aneurysm rupture. However, Sm is only half of the AAA rupture equation. The other half is the degree of damage to the aneurysm wall due to several factors which lower wall rupture strength including atherosclerosis and deformation associated with growth. Mechanical failure or rupture occurs when arterial pressure induced wall stress exceeds the ability of the damaged wall to remain intact. While determination of aneurysm wall rupture strength in vivo is an elusive and complex problem, serum biomarker concentrations may indirectly provide an estimate of the degree of AAA wall damage. This study gives a glimpse of the relationships between these variables.

Duplex Ultrasound and Contrast-Enhanced Ultrasound Versus Computed Tomography for the Detection of Endoleak after EVAR: Systematic Review and Bivariate Meta-Analysis - Corrected Proof

2010-02-01

Abstract: Introduction: Contrast-enhanced computed tomography (CT) has become the ‘gold-standard’ imaging modality for surveillance following EVAR. However repeated CT causes cumulative contrast related renal injury. Duplex ultrasound (USS) and contrast-enhanced (non-nephrotoxic) duplex scanning (CEUS) are less invasive but considered less accurate than CT. The aim of this study was to determine the diagnostic accuracy of imaging modalities used to detect endoleak. Accordingly, we undertook a systematic review and meta-analysis of the evidence base for USS and CEUS compared to CT following EVAR.Methods: Medline, Embase, trial registries, conference proceedings and article reference lists were searched to identify trials comparing USS or CEUS with CT following EVAR. Contrast-enhanced computed tomography was taken as the ‘gold-standard’ investigation. USS and CEUS were compared to CT in separate meta-analyses.Results: Twenty-one studies in 2601 patients compared USS with CT. The sensitivity of USS at detecting endoleak was 0.77 (95% CI 0.64–0.86; I2=0.82) and pooled specificity 0.94 (95% CI 0.88–0.97; I2=0.90). Seven studies (288 patients) compared CEUS vs CT. The pooled sensitivity was 0.98 (95% CI 0.90–0.99; I2=0.32) and specificity 0.88 (95% CI 0.78–0.94; I2=0.67).Conclusion: This study confirms that unenhanced USS has poor sensitivity for endoleak detection; however CEUS is a highly sensitive modality. These results should be interpreted with some caution due to heterogeneity in analysed trials and further research is needed to evaluate the efficacy of CEUS before it can be utilised as the primary imaging modality for EVAR surveillance.

Growth and Risk Factors for Expansion of Dilated Popliteal Arteries - Corrected Proof

R. Magee, F. Quigley, M. McCann, P. Buttner, J. Golledge — 2010-02-01

Abstract: Objectives: The aims of this study were to investigate the change in maximum diameter of ectatic popliteal arteries during ultrasound surveillance and assess clinical predictors of their expansion.Methods: Over a ten year period 67 patients with ectasia affecting one (n = 1) or both (n = 66) popliteal arteries entered this surveillance study. Patients were followed for a median of 3.1 years, at a median scan interval of 7.6 months.Results: Growth of ectatic popliteal arteries was typically slow (<1 mm/yr). Initial artery diameter at entry to the study was not found to be predictive of subsequent growth. Seven patients followed for a median of 2 years had an expansion in popliteal artery diameter to ≥20 mm during follow-up. All of these patients had undergone aneurysm repairs at other arterial sites and none of them had diabetes. These participants also had a significantly higher rate of previous intervention of the contralateral popliteal artery in comparison to those that did not reach the 20 mm threshold (p < 0.001). Growth profiles of arteries that underwent significant expansion during surveillance were frequently characterised by a staccato pattern.Conclusions: Expansion of ectatic popliteal arteries is typically slow but difficult to predict. Trends observed in this study suggest that patients with extra-popliteal aneurysms, patients with previously treated contralateral popliteal artery ectasia and those who are not diabetics may be more prone to significant expansion. Further studies are required to validate these potential growth predictors.

World Federation of Vascular Societies: Presidential Address - Corrected Proof

H. Sillesen — 2010-01-28

Abstract: The presidential address describes briefly the history of the World Federation for Vascular Societies (WFVS) and its objectives. Vascular Surgery today includes interventional procedures (open surgical and endovascular) in addition to risk factor reduction and medical treatment. It is equally important to train in clinical investigative methods, non-surgical treatment, decision making as is training in technical aspects of interventions. Similarly, it is vital, that the vascular specialist always recommends the treatment which is best to the individual patient, not only what he can do or what is best for other reasons, i.e. financial. Due to the increasing complex procedures - endovascular evolution and what is then “left” for open surgery - specialisation into “mainly open vascular surgeon” and “mainly endovascular surgeon” preceded by a common basic training into both, seems unavoidable. Similar, in order to be able to train with relevant case mix and numbers, and in order always to have both complex open and endovascular skills on call 24 hours per day, 365 days a year, centralisation into larger units is necessary. The WFVS is important simply looking at the huge demographic differences throughout the world. In addition, for introduction of new treatments, training issues and dissemination of science a global organisation like the WFVS is needed.

Foam Sclerotherapy of the Saphenous Veins: Randomised Controlled Trial with or without Compression - Corrected Proof

C.M. Hamel-Desnos, B.J. Guias, P.R. Desnos, A. Mesgard — 2010-01-25

Abstract: Objectives: This study aims to compare the efficacy and side effects of foam sclerotherapy of the saphenous veins with or without post-treatment compression using graduated elastic stockings.Design: This is a prospective open randomised controlled trial conducted in two centres.Patients and methods: Sixty patients with incompetent great (GSV) or small saphenous veins (SSV) underwent ultrasound-guided foam sclerotherapy. Randomisation was conducted immediately after sclerotherapy to two parallel groups, one (CG) with compression stockings (15–20 mmHg worn during the day, for 3 weeks) and the other (WCG) without compression. Efficacy of sclerotherapy and all of the side effects were assessed, including side effects in the treated region.On days 14 and 28, clinical and duplex ultrasound (DUS) assessments were performed by independent experts. Patients also completed quality of life (QOL), symptom questionnaires and provided satisfaction scores.Results: Five men and 55 women ranging in age from 32 to 78 (mean 57 years) years were included: 29 in the WCG and 31 in the CG group. On day 28, abolition of venous reflux and occlusion of the vein was obtained in 100% of the cases in both groups. The length of the occluded vein was the same in both groups (mean 36 cm for the GSV and 30 cm for the SSV) as was the mean diameter of the occluded vein (5 mm). Symptoms and QOL questionnaires showed equivalent improvement in both groups on day 28 compared to pre-treatment assessments. Side effects were few with no statistical difference between the two groups. Patient satisfaction scores were high in both groups for the outcome of sclerotherapy results, and good or very good for compression in 50% of the CG cases.Conclusion: We found no difference between compression and control groups when comparing efficacy, side effects, satisfaction scores, symptoms and QOL. Further studies are required to establish the role of compression in sclerotherapy and to evaluate other compression strategies.

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

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

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

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

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

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

Endovascular Therapy for Patients with Renal Angiomyolipoma Presenting with Retroperitoneal Haemorrhage - Corrected Proof

2010-01-22

Abstract: We report our experience treating four patients with acutely bleeding angiomyolipoma (AML) of sizes between 4 and 12 cm who were managed with endovascular embolisation with a mean follow-up of 10 months. In our case series, we demonstrate that endovascular embolisation in the acute setting for bleeding AMLs is a viable treatment option. AML should be in the differential diagnosis of acutely bleeding renal masses, even when there is no fat assessed by computed tomography (CT) imaging in the renal mass.

Commentary on “Natural History of Thoracoabdominal Aneurysm in High-Risk Patients” by P.A. Hansen, J.M. Richards, A.L. Tambyraja, L. Khan and R.T. Chalmers - Corrected Proof

G. Melissano, R. Chiesa — 2010-01-22

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

Does EVAR Alter the Rate of Cardiovascular Events in Patients with Abdominal Aortic Aneurysm Considered Unfit for Open Repair? Results from the Randomised EVAR Trial 2 - Corrected Proof

2010-01-22

Abstract: Objectives: To investigate whether EndoVascular Aneurysm Repair (EVAR) influences the rate of cardiovascular events (fatal or non-fatal myocardial infarction or stroke) in patients with abdominal aortic aneurysm (AAA) considered unfit for open repair.Design: Randomised controlled trial.Materials: Between 1999 and 2004, 404 patients with large AAA considered unfit for open repair were randomised to EVAR or no surgical intervention across 33 UK hospitals and followed until July 2009.Methods: The Customised Probability Index was used to determine fitness for each patient and Cox regression was used to compare time to first cardiovascular event between randomised groups and levels of fitness.Results: During an average of 2.8 years of follow-up, 67 first cardiovascular events occurred with a non-significantly higher event rate in the EVAR group compared to the no intervention group (6.6 versus 5.1 events per 100 person years); adjusted hazard ratio 1.42 [95% CI 0.87–2.34], p=0.156. There was no evidence to suggest that the hazard ratio between randomised groups changed with level of fitness (p=0.378).Conclusions: Cardiovascular event rates were high in these unfit patients and medical therapy was sub-optimal. Events rates were slightly higher in the EVAR group but this was not statistically significant.