European Journal of Vascular & Endovascular Surgery - Articles in Press

Improving Quality of Life in Patients with Peripheral Arterial Disease: An Important Goal - Corrected Proof

P. Kolh — 2010-08-27

For patients suffering from peripheral arterial disease (PAD), quality of life (QoL) has become as important as medical outcome end points, such as mortality and morbidity, to evaluate the effect of disease and treatment. Furthermore, impaired QoL has been associated with an increased risk of poor clinical course and prognosis. Measures of PAD severity, such as the ankle–brachial index (ABI), may predict functional impairment, but they are only partially associated with QoL. Therefore, other factors that may influence QoL in PAD patients have to been considered.

Open Repair for Ruptured Abdominal Aortic Aneurysm and the Risk of Spinal Cord Ischemia: Review of the Literature and Risk-factor Analysis - Corrected Proof

2010-08-27

Abstract: Objectives: Spinal cord ischemia after open surgical repair for rAAA is a rare event. We estimated the current incidence and tried to identify risk factors. We also report a new case.Methods: Group A consisted of 10 reports on open repair for rAAA from 1980 until 2009. Only series of ≥100 patients were considered to estimate the incidence. Thirty three case reports from 1956 until 2009 were identified (group B). Case reports from group B were not encountered in group A. Group B patients were stratified according to the type of neurological deficit as described by Gloviczki (type I complete infarction and type II infarction of the anterior two third).Results: Group A consisted of 1438 patients. In group A 86% were male with a mean age of 72.1 years. The incidence of post-operative paraplegia was 1.2% (range 0–2.8%). In-hospital mortality was 46.9%. Of the 33 patients of group B were 86% male with a mean age of 68.0 years. Most patients developed a type I (42%) or type II (33%) deficit. In-hospital mortality was 51.6%. No significant differences between different types were encountered.Conclusion: Spinal cord ischemia after ruptured AAA is a rare complication with an incidence of 1.2% (range 0–2.8%).

Trans-Atlantic Debate: Is a Randomised Trial Necessary to Determine Whether Endovascular Repair is the Preferred Management Strategy in Patients with Ruptured Abdominal Aortic Aneurysms? - Corrected Proof

J.-B. Ricco, T.L. Forbes — 2010-08-27

Mortality rates following repair of ruptured abdominal aortic aneurysms have remained depressingly high over the last number of decades despite advances in anesthesia and perioperative care. Prior to the introduction of endovascular repair, refinements in surgical technique had been few and far between. It was not until fairly recently that we finally observed a reduction in mortality coinciding with the wider adoption of endovascular repair. So, the case is closed, right? Endovascular repair should be widely adopted in all suitable patients? Well … not exactly. The following debate centers around what level of evidence is required to answer this question.

Trans-Atlantic Debate: Is a Randomised Trial Necessary to Determine Whether Endovascular Repair is the Preferred Management Strategy in Patients with Ruptured Abdominal Aortic Aneurysms? - Corrected Proof

J.-B. Ricco, T.L. Forbes — 2010-08-27

Given the poor outcomes after open repair (OR) for ruptured abdominal aortic aneurysms (RAAA), as well as the low 30-day mortality associated with endovascular aortic repair (EVAR) in elective patients, an increasing number of centers have established protocols to use EVAR for RAAA (REVAR).

Use of B-Type Natriuretic Peptide to Predict Blood Pressure Improvement after Percutaneous Revascularisation for Renal Artery Stenosis - Corrected Proof

2010-08-26

Abstract: Objectives: The purpose of this study was to evaluate the utility of B-type natriuretic peptide (BNP) to predict blood pressure (BP) response in patients with renal artery stenosis (RAS) after renal angioplasty and stenting (PTRA).Methods: In 120 patients with RAS and hypertension referred for PTRA, 24-h ambulatory BP recordings were obtained before and 6 months after intervention. BNP was measured before, 1 day and 6 months after PTRA.Results: BP improved in 54% of patients. Median BNP levels pre-intervention were 97 pg ml−1 (interquartile range (IQR) 35–250) and decreased significantly within 1 day of PTRA to 62 pg ml−1 (IQR 24–182) (p 50 pg ml−1 was seen in 79% of patients with BP improvement compared with 56% in patients without improvement (p = 0.01). In a multivariate logistic regression analysis, BNP >50 pg ml−1 was significantly associated with BP improvement (odds ratio (OR) 4.0, 95% CI 1.2–13.2).Conclusions: BNP levels are elevated in patients with RAS and decrease after revascularisation. Although BNP does not seem useful as a continuous variable, pre-interventional BNP >50 pg ml−1 may be helpful to identify patients in whom PTRA will improve BP.

A Retrospective Study of Intravascular Ultrasound use in Patients Undergoing Endovascular Aneurysm Repair: Its Usefulness and a Description of the Procedure - Corrected Proof

K. Hoshina, M. Kato, T. Miyahara, A. Mikuriya, N. Ohkubo, T. Miyata — 2010-08-26

Abstract: Objectives: To verify the usefulness and limitation of intravascular ultrasound (IVUS) in endovascular aneurysm repair (EVAR).Methods: A total of 112 consecutive patients, who underwent EVAR to treat abdominal aortic aneurysms, were examined retrospectively. Of these, 33 patients were assigned to the IVUS group because of renal failure, a suspected allergy to contrast agents or anatomical difficulties; the remaining 79 patients were assigned to the non-IVUS group.Results: Patients in the IVUS group required fewer intra-arterial contrast agents (IACAs) than those in the non-IVUS group (67±34ml vs. 123±50ml; p<0.01). Blood loss and operation time were comparable between the two groups. No patients died within 30 days of the operation. Three major renal complications occurred in the non-IVUS group. Renal deterioration evaluated by chronic kidney disease (CKD) stage was found to a greater extent in the non-IVUS group.Conclusions: IVUS is a powerful auxiliary method in EVAR for reducing the required volume of contrast agents. The combination of IVUS and IACA usage showed good overall performance; thus, we propose the routine use of IVUS in EVAR procedures.

Endovascular Repair of a Ruptured Popliteal Artery Aneurysm Associated with Popliteal Arteriovenous Fistula - Corrected Proof

G. Pratesi, J. Marek, A. Fargion, R. Pulli, W. Dorigo, C. Pratesi — 2010-08-26

Abstract: Popliteal artery aneurysms (PAAs) represent the most common peripheral arterial aneurysm and are a significant cause of patient morbidity and limb loss. Complications of PAA include distal embolisation, thrombosis and, rarely, rupture. Whereas open surgical repair remains the gold standard, endovascular exclusion has been demonstrated to be a valid alternative in selected patients.We present an unusual case of ruptured PAA associated with popliteal vein arteriovenous fistula that was successfully treated with an endovascular approach.In our opinion, higher-risk patients as well as patients presenting with rupture may constitute a subgroup warranting an endovascular approach whenever possible.

A Unique Case of ‘Superficial’ Posterior Tibial Artery – Anatomical and Clinical Considerations - Corrected Proof

L. Jelev, G.P. Georgiev — 2010-08-26

We report a unique dissectional case of ‘superficial’ posterior tibial artery, unknown in anatomical and surgical literature. Arising from the popliteal artery, the aberrant posterior tibial artery coursed medially and passed between the tendons of the soleus and the medial head of gastrocnemius muscles. Covered by the crural fascia, the variant artery descended along the medial border of the tibia, parallel to the great saphenous vein. The arterial variation described here, though rare, could present some diagnostic and therapeutic challenges in the field of vascular surgery.

Comments regarding ‘A New Endovascular Approach to Exclude Isolated Bilateral Common Iliac Artery Aneurysms'. Eur J Vasc Endovasc Surg Extra 2010; 19(6) e55–7 - Corrected Proof

J. Ghosh — 2010-08-26

I read with interest the innovative technique described by Frigatti et al. Therein, a bilateral iliac aneurysm is excluded endoluminally and the ‘chimney’ technique is utilized to preserve the flow into one internal iliac artery (IIA) whilst the other was intentionally occluded. In cases such as these it is useful to reconsider the sequelae of unilateral and bilateral iliac occlusion. Contrary to popular perception, intentional unilateral IIA occlusion appears to carry a similar risk of symptoms as bilateral, ranging from 9 to 45%. Neither statistically significant difference in incidence of pelvic ischaemia nor sexual dysfunction has been shown between unilateral and bilateral IIA occlusions. Accordingly efforts to preserve bilateral IIA perfusion are justifiable, particularly in younger and active patients.

Duplex Ultrasound Outcomes Following Ultrasound-Guided Foam Sclerotherapy of Symptomatic Primary Great Saphenous Varicose Veins - Corrected Proof

K.A.L. Darvall, G.R. Bate, D.J. Adam, S.H. Silverman, A.W. Bradbury — 2010-08-23

Abstract: Objectives: To describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of primary great saphenous varicose veins (GSVV).Methods: A consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic primary GSVV.Results: 344 treated legs (CEAP C2/3 237, C4 72, C5 14, C6 21) belonging to 278 patients (103 male) of median age 57 (range 21–89) years were enrolled between November 2004 and May 2007. The median volume of foam used was 10 (range 2–16) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 333 (96.8%) and 308 (89.5%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 323 (97.0%) and 294 (95.5%) legs respectively; and by two sessions of UGFS in 329 (98.8%) and 304 (98.7%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 18/286 (6.3%) AK and 23/259 (8.9%) BK-GSV segments after 12 months follow-up.Conclusions: A single session of UGFS can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV. Recanalisation at 12 months is superior to that reported after surgery and similar to that observed following other minimally invasive techniques.

Quality Control in Systematic Reviews and Meta-analyses - Corrected Proof

M.J. Bown, A.J. Sutton — 2010-08-23

Abstract: Systematic reviews and meta-analyses are being submitted to, and being published by biomedical journals with increasing frequency. In order to maintain the utility of such publications and avoid misguidance it is important that these studies are conducted to a high standard. This article aims to provide guidance both for those researchers undertaking and reporting such studies and for the readers of such articles. Details of a suggested method for conducting a systematic review are given, including methods for literature searches, data abstraction and data extraction followed by a brief overview of common methods used for meta-analyses and the interpretation of the results of meta-analysis.

Evaluation of an Electromagnetic 3D Navigation System to Facilitate Endovascular Tasks: A Feasibility Study - Corrected Proof

R. Sidhu, J. Weir-McCall — 2010-08-23

Abstract: Introduction: We describe a novel approach to arterial cannulation using the StealthStation® Guidance System (Medtronic, USA). This uses electromagnetic technology to track the guidewire, displaying a 3D image of the vessel and guidewire.Methods: The study was performed on a ‘bench top’ simulation model called the Cannulation Suite comprising of a silicone aortic arch model and simulated fluoroscopy. The accuracy of the StealthStation® was assessed. 16 participants of varying experience in performing endovascular procedures (novices: 6 participants, ≤5 procedures performed; intermediate: 5 participants, 6–50 procedures performed; experts: 5 participants, >50 procedures performed) underwent a standardised training session in cannulating the left subclavian artery on the model with the conventional method (i.e. with fluoroscopy) and with the StealthStation®. Each participant was then assessed on cannulating the left subclavian artery using the conventional method and with the StealthStation®. Performance was video-recorded. The subjects then completed a structured questionnaire assessing the StealthStation®.Results: The StealthStation® was accurate to less than 1mm [mean (SD) target registration error 0.56mm (0.91)]. Every participant was able to complete the cannulation task with a significantly lower use of fluoroscopy with the navigation system compared with the conventional method [median 0s (IQR 0–2) vs median 14s (IQR 10–19), respectively; p=<0.001]. There was no significant difference between the StealthStation® and conventional method for: total procedure time [median 17s (IQR 9–53) vs median 21s (IQR 11–32), respectively; p=0.53]; total guidewire hits to the vessel wall [median 0 (IQR 0–1) vs median 0 (IQR 0–1), respectively; p=0.86]; catheter hits to the vessel wall [median 0.5 (IQR 0–2) vs median 0.5 (IQR 0–1), respectively; p=0.13]; and cannulation performance on the global rating scale [median score, 39/40 (IQR 28–39) vs 38/40 (IQR 33–40), respectively; p=0.40]. The intra-class correlation coefficient for agreement between video-assessors for all scores was 0.99. 88% strongly agreed that the StealthStation® can potentially decrease exposure of the patient to contrast and radiation.Conclusion: Arterial cannulation is feasible with the StealthStation®.

Doppler Ultrasonography-Aided Early Diagnosis of Venous Thromboembolism after Total Knee Arthroplasty - Corrected Proof

H. Kume, Y. Inoue, A. Mitsuoka, N. Sugano, T. Morito, T. Muneta — 2010-08-23

Abstract: Objectives: Postoperative deep venous thrombosis (DVT) is usually asymptomatic but can result in a fatal pulmonary embolism (PE). To assess the ability of transcranial Doppler (TCD) ultrasound apparatus to detect venous emboli in patients who had undergone total knee arthroplasty (TKA).Methods: Forty-eight patients undergoing TKA were examined postoperatively by using compression ultrasonography, computed tomographic angiography, and TCD ultrasonography that detected high-intensity transient signals (HITS) in femoral veins. An original scoring system based on both the number of HITS and the locations of DVT was tested for its accuracy in predicting PE development.Results: Twenty-three of the 48 patients had DVT postoperatively, and 8 had an asymptomatic PE. The sensitivity and specificity of the HITS assessment alone in identifying PE development were 75% and 92.5%, respectively. The scoring system, however, had a sensitivity of 100% and a specificity of 85% and the area under the receiver operating characteristic (ROC) curve (AUC) was 0.96.Conclusions: Application of a scoring system based on the detection of both DVT and HITS may be an effective and efficient method of screening for PE after knee arthroplasty.

Carotid Endarterectomy for Symptomatic, but “Haemodynamically Insignificant” Carotid Stenosis - Corrected Proof

R.M. Ahmed, J.P. Harris, C.S. Anderson, V. Makeham, G.M. Halmagyi — 2010-08-20

Abstract: Objective: Carotid endarterectomy (CEA) guidelines in symptomatic carotid stenosis are based on NASCET and ECST criteria with 70% or greater carotid stenosis as estimated from a catheter angiogram the major indication. This has several problems: (1) lack of reliable correlation between non-invasive imaging and catheter angiography, which has been largely superseded by non-invasive imaging in investigating carotid stenosis; (2) errors inherent in estimating the degree of stenosis from catheter angiography; (3) disregard for the fact that stroke risk also depends on plaque stability, and number of ischaemic events.Methods: A retrospective review of ischaemic events, imaging results, operative findings, surgical complications and stroke-free follow-up in 31 patients presenting over a 23 year period with TIA/stroke (symptoms lasting > 24 h and/or imaging evidence of infarction) who had 70% or less carotid stenosis (on non-invasive imaging), but nonetheless underwent CEA.Results: Nineteen patients had small strokes, 7 had TIAs and 5 had ocular events; 28 patients had features of unstable plaque on imaging; 19 patients experienced multiple events before CEA. All had haemorrhagic, ruptured plaque at CEA. One patient suffered an intra-operative stroke, only 1 patient suffered a further stroke/TIA (mean follow-up 4.2 years).Conclusion: To predict the likelihood of major stroke in symptomatic carotid stenosis and the benefit of CEA, plaque stability and the number of ischaemic events might be as important as an estimate of the degree of stenosis.

The Impact of Hypovolaemic Shock on the Aortic Diameter in a Porcine Model - Corrected Proof

2010-08-20

Abstract: Objectives: To investigate the impact of hypovolaemic shock on the aortic diameter in a porcine model, and to determine the implications for the endovascular management of hypovolaemic patients with traumatic thoracic aortic injury (TTAI).Materials and methods: The circulating blood volume of seven Yorkshire pigs was gradually lowered in 10% increments. At 40% volume loss, an endograft was deployed in the descending thoracic aorta, followed by gradual fluid resuscitation. Potential changes in aortic diameter during the experiment were recorded using intravascular ultrasound (IVUS).Results: The aortic diameter decreased significantly at all evaluated levels during blood loss. The ascending aortic diameter decreased on average with 38% after 40% blood loss (range 24–62%, p = 0.018), the descending thoracic aorta with 32% (range 18–52%, p = 0.018) and the abdominal aorta with 28% (range 15–39%, p = 0.018). The aortic diameters regained their initial size during fluid resuscitation.Conclusion: The aortic diameter significantly decreases during blood loss in this porcine model. If these changes take place in hypovolaemic TTAI patients as well, it may have implications for thoracic endovascular aortic repair (TEVAR). Increased oversizing of the endograft, or additional computed tomography (CT) or IVUS imaging after fluid resuscitation for more adequate aortic measurements, may be needed in TTAI patients with considerable blood loss.

Association between Biomechanical Structural Stresses of Atherosclerotic Carotid Plaques and Subsequent Ischaemic Cerebrovascular Events – A Longitudinal in Vivo Magnetic Resonance Imaging-based Finite element Study - Corrected Proof

2010-08-19

Abstract: Background: High-resolution magnetic resonance (MR) imaging has been used for MR imaging-based structural stress analysis of atherosclerotic plaques. The biomechanical stress profile of stable plaques has been observed to differ from that of unstable plaques; however, the role that structural stresses play in determining plaque vulnerability remains speculative.Methods: A total of 61 patients with previous history of symptomatic carotid artery disease underwent carotid plaque MR imaging. Plaque components of the index artery such as fibrous tissue, lipid content and plaque haemorrhage (PH) were delineated and used for finite element analysis-based maximum structural stress (M-C Stress) quantification. These patients were followed up for 2 years. The clinical end point was occurrence of an ischaemic cerebrovascular event. The association of the time to the clinical end point with plaque morphology and M-C Stress was analysed.Results: During a median follow-up duration of 514 days, 20% of patients (n = 12) experienced an ischaemic event in the territory of the index carotid artery. Cox regression analysis indicated that M-C Stress (hazard ratio (HR): 12.98 (95% confidence interval (CI): 1.32–26.67, p = 0.02), fibrous cap (FC) disruption (HR: 7.39 (95% CI: 1.61–33.82), p = 0.009) and PH (HR: 5.85 (95% CI: 1.27–26.77), p = 0.02) are associated with the development of subsequent cerebrovascular events. Plaques associated with future events had higher M-C Stress than those which had remained asymptomatic (median (interquartile range, IQR): 330 kPa (229–494) vs. 254 kPa (166–290), p = 0.04).Conclusions: High biomechanical structural stresses, in addition to FC rupture and PH, are associated with subsequent cerebrovascular events.

Part One. For the Motion - Corrected Proof

J.T. Powell, R.J. Hinchliffe — 2010-08-18

Should the potential benefits and risks of endovascular repair of ruptured abdominal aortic aneurysm (rAAA) on a population-based or national scale be evaluated by evidence or by expert opinion? By evidence, of course, with the best evidence coming from randomised controlled trials (RCTs).

Is Duplex Ultrasound Scanning for Peripheral Arterial Disease of the Lower Limb a Non-invasive Alternative or an Adjunctive to Angiography? - Corrected Proof

S.K. Kakkos, I.A. Tsolakis — 2010-08-18

Duplex ultrasound scanning (DUS), a non-invasive and low-cost imaging modality, has been extensively used to investigate peripheral arterial disease (PAD). Numerous studies have compared DUS with digital subtraction angiography (DSA) in the past, and most of them found good correlation, particularly in the supragenicular segments. Interestingly, interobserver variation in DUS and DSA interpretation is equally frequent.

Treatment of Mycotic Aneurysms with Involvement of the Abdominal Aorta: Single-centre Experience in 44 Consecutive Cases - Corrected Proof

M. Dubois, K. Daenens, S. Houthoofd, W.E. Peetermans, I. Fourneau — 2010-08-18

Abstract: Objective: To review our management of mycotic aneurysms involving the abdominal aorta over the past 2 decades to assess the safety and efficacy of in-situ and extra-anatomic repair combined with antibiotic treatment.Materials and methods: From March 1990 to August 2008, 44 patients with a mycotic aneurysm involving the abdominal aorta were treated at our University Hospital. For all patients, we recorded the aetiology, clinical findings and anatomic location of the aneurysm, as well as bacteriology results, surgical and antibiotic therapy and morbidity and mortality.Results: Twenty-one (47.7%) of the mycotic aneurysms had already ruptured at the time of surgery. Free rupture was present in nine patients (20.5%). Contained rupture was observed in 12 patients (27.3%).Urgent surgery was performed in 18 cases (40.9%). Revascularisation was achieved by in-situ reconstruction in 37 patients (84.1%), while extra-anatomic reconstruction was performed in six patients (13.6%). One patient (2.3%) was treated with a combined in-situ and extra-anatomic reconstruction. In one case (2.3%), endovascular aneurysm repair (EVAR) was performed.In-hospital mortality was 22.7%, 50% in the extra-anatomic reconstruction group and 18.9% in the in-situ repair group. One-third (33.3%) of our patients, who presented with a ruptured mycotic aneurysm died in the peri-operative period. This mortality was 13% in the patient-group presenting with an intact aneurysm.Of the 34 surviving patients, 12 patients (27.3% of surviving patients died after discharge from our hospital. In half of these patients, an acute cardiac event was to blame. Three patients (8%) showed re-infection after in-situ reconstruction.Conclusion: Management of mycotic aortic aneurysms remains a challenging problem. The results of surgery depend on many factors. In our experience, in-situ repair remains a feasible and safe treatment option for patients who are in good general condition at the time of surgery.

A Rare Case of Aortic Dissection and Primary Hyperaldosteronism - Corrected Proof

K.L. Harvey, C.V. Riga, M. O’Connor, M.S. Hamady, N. Chapman, R.G.J. Gibbs — 2010-08-16

Introduction: Rare case of a 39-year-old presenting with the triad of aortic dissection, hypertension and aldosterone-secreting adrenal tumour. Report: We discuss his management, in the acute setting and long term.

Carotid Artery Disease: Novel Pathophysiological Mechanisms Identified by Gene-expression Profiling of Peripheral Blood - Corrected Proof

2010-08-16

Abstract: Object: The pathogenesis of carotid artery stenosis (CAS) as well as the mechanisms underlying the different localisation of the atherosclerotic lesions remains poorly understood. We used microarray technology to identify novel systemic mediators that could contribute to CAS pathogenesis.Moreover, we compared gene-expression profile of CAS with that of patients affected by abdominal aortic aneurysm (AAA), previously published by our group.Methods and results: By global gene-expression profiling in a pool of 10 CAS patients and 10 matched controls, we found 82 genes differentially expressed. Validation study in pools used for profiling and replication study in larger numbers of CAS patients (n = 40) and controls (n = 40) of 14 genes by real-time polymerase chain reaction (RT-PCR) confirmed microarray results. Fourteen out of 82 genes were similarly expressed in AAA patients. Gene ontology analysis identified a statistically significant enrichment in CAS of differentially expressed transcripts involved in immune response and oxygen transport. Whereas alteration of oxygen transport is a common tract of the two localisations, alteration of immune response in CAS and of lipid metabolic process in AAA represents distinctive tracts of the two atherosclerotic diseases.Conclusions: We describe the systemic gene-expression profile of CAS, which provides an extensive list of potential molecular markers.

Endovascular Treatment of an Infected Carotid Prosthetic Patch and Pseudo-aneurysm - Corrected Proof

G. Harrison, R. McWilliams, R. Fisher — 2010-08-16

Prosthetic patch infection following carotid endarterectomy (CEA) is rare and usually requires surgical excision of the patch and carotid ligation or reconstruction. We present a case of carotid patch infection with pseudoaneurysms successfully treated with a covered stent. Follow-up to 31 months demonstrated no clinical, biochemical or microbiological evidence of local or systemic infection and surveillance duplex confirmed continued exclusion of the pseudoaneurysm. At fourteen months, symptomatic proximal and distal restenoses were successfully restented. The patient then remained asymptomatic, but the distal stenosis recurred. Endovascular treatment may be an alternative to surgery, particularly in those who are high risk.

Comments regarding “Carotid Endarterectomy for Symptomatic, but “Haemodynamically Insignificant” Carotid Stenosis” - Corrected Proof

J.P. Archie — 2010-08-16

Carotid endarterectomy is considered the treatment of choice for patients with focal embolic symptoms and ipsilateral significant carotid stenosis. In general, these patients have duplex ultrasound and/or imaging studies that demonstrate internal carotid stenosis of 70–75% or greater by ESCT criteria, of 50% or greater by NASCET criteria or, as in recent years, by duplex scan criteria scaled to either the ESCT or NASCET criteria. There is little data and no general guidelines for management of symptomatic patients with marginally significant or lesser degrees of stenosis. Surgeons frequently performing CEA over many years only occasionally or infrequently encounter this small sub-set of symptomatic patients with hemodynamically insignificant mild or low-moderate stenosis. Given such a patient, physicians are faced with a difficult management decision. Few would choose CAS for symptomatic patients in general and even less likely in this small group of patients.

Variations in Surgical Procedures for Hind Limb Ischaemia Mouse Models Result in differences in Collateral Formation - Corrected Proof

2010-08-13

Abstract: Objective: To identify the optimal mouse model for hind limb ischaemia, which offers a therapeutic window that is large enough to detect improvements of blood flow recovery, for example, using cell therapies.Materials and Methods: Different surgical approaches were performed: single coagulation of femoral and iliac artery, total excision of femoral artery and double coagulation of femoral and iliac artery. Blood flow restoration was analysed with Laser Doppler Perfusion Imaging (LDPI). Immuno-histochemical stainings, angiography and micro-computed tomography (CT) scans were performed for visualisation of collaterals in the mouse.Results: Significant differences in flow restoration were observed depending on the surgical procedure. After single coagulation, blood flow already restored 100% in 7 days, in contrast to a significant delayed flow restoration after double coagulation (54% after 28 days, P < 0.001). After total excision, blood flow was 100% recovered within 28 days. Compared with total excision, double coagulation displayed more pronounced corkscrew phenotype of the vessels typical for collateral arteries on angiographs.Conclusion: The extent of the arterial injury is associated with different patterns of perfusion restoration. The double coagulation mouse model is, in our hands, the best model for studying new therapeutic approaches as it offers a therapeutic window in which improvements can be monitored efficiently.

Carotid Artery Reconstruction for Infected Carotid Patches - Corrected Proof

2010-08-12

Abstract: Objectives: Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP.Design: Single-center retrospective study.Methods: 10-year review of the surgical treatment of ICPP.Results: Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery (n = 6), cadaveric homograft (n = 3), long saphenous vein (n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus (n = 3), Corynebacterium propionibacterium (n = 1) and Streptococcus anginous (n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3–108 months).Conclusion: Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.

Comment on “PTFE Bypass to Below-knee Arteries: Distal Vein Collar or Not? A Prospective Randomised Multicentre Study” - Corrected Proof

M.J. Gough — 2010-08-09

The authors of this study have raised some relevant points about the data published by the Joint Vascular Research Group (JVRG). In particular they point out that the study only reliably assessed the benefit of a vein cuff following below-knee femoro-popliteal bypass and not femoro-distal surgery because of small numbers. However in their own study primary patency was only assessed in 13 of such patients at 3 years.

Comments regarding ‘Assessing the Quality of Surgical Care in Vascular Surgery; Moving from Outcome Towards Structural and Process Measures’ - Corrected Proof

J.J. Earnshaw — 2010-08-09

Vascular surgery is a unique discipline. People with no symptoms who have an aortic aneurysm or who have had focal neurological symptoms are advised they are in significant danger, and offered intervention, but with a risk of morbidity and mortality. It is therefore vital that all vascular interventions are as safe as possible. The aim to improve quality is fundamental to the specialty of vascular surgery.

Aortic and Iliac Fixation of Seven Endografts for Abdominal-aortic Aneurysm Repair in an Experimental Model Using Human Cadaveric Aortas - Corrected Proof

2010-08-09

Abstract: Objective: To evaluate the proximal and distal (iliac) fixation of seven self-expanding endografts, used in the endovascular treatment (EVAR) of abdominal-aortic aneurysm (AAA), by measuring the displacement force (DF) necessary to dislocate the devices from their fixation sites.Methods: A total of 20 human cadaveric aortas were exposed, left in situ and transected to serve as fixation zones. The Anaconda, EndoFit aorto-uni-iliac, Endurant, Powerlink, Excluder, Talent and Zenith stent grafts were deployed and caudal force was applied at the flow divider, through a force gauge. The DF needed to dislocate each device ≥ 20 mm from the infrarenal neck was recorded before and after moulding-balloon dilatation. Cephalad force was similarly applied to each iliac limb to assess distal fixation before and after moulding-balloon dilatation.Results: Endografts with fixation hooks or barbs displayed a significantly higher DF necessary to dislocate the proximal portion compared with devices with no such fixation modalities (p < 0.001). Balloon dilatation produced a significant increase in DF in both devices with (p < 0.001) or without (p = 0.003) hooks or barbs. Suprarenal support did not enhance proximal fixation (p = 0.90). Balloon dilatation significantly increased the DF necessary to dislodge the iliac limbs (p = 0.007).Conclusions: Devices with fixation hooks displayed higher proximal fixation. Moulding-balloon dilatation increased proximal and distal fixation. Suprarenal support did not affect proximal fixation.

Effect of Hospital and Surgeon Volume on Patient Outcomes Following Treatment of Abdominal Aortic Aneurysms: A Systematic Review - Corrected Proof

2010-08-06

Abstract: Objectives: This systematic review assessed the efficacy of centralisation for the treatment of unruptured and ruptured abdominal aortic aneurysms. Patient outcomes achieved by low and high volume hospitals/surgeons, including morbidity, mortality and length of hospital stay, were used as proxy measures of efficacy.Design: Systematic review was designed to identify, assess and report on peer-reviewed articles reporting outcomes from unruptured and ruptured abdominal aortic aneurysms. No language restriction was placed on the databases searched.Materials: Only peer-reviewed journals articles were included.Methods: To ensure the contemporary nature of this review, only studies published between January 1997 and June 2007 were sought. Studies were included if they reported on at least one volume type and patient outcome.Results: Twenty two studies were included in this review. In the majority of group assessments, the number of studies reporting statistical significance was similar to the number of studies reporting no statistical significance.Conclusion: The paucity of studies reporting statistically significant results demonstrates that although this evidence exists, its potential to be overstated must also be taken into account when drawing conclusions as to its efficacy for twenty first century healthcare systems.

Abdominal Aortic Aneurysm Surgery in Renal, Cardiac and Hepatic Transplant Recipients - Corrected Proof

U. Sadat, E.L. Huguet, K. Varty — 2010-08-06

Abstract: With advancements in transplantation and improved long-term allograft survival, the once rare clinical scenario of an abdominal aortic aneurysm (AAA) in a patient with a functioning allograft has become much more frequent. In transplant recipients, AAA repair has the potential to cause irreversible ischaemic injury to the transplanted organ. Different case series and case reports have mentioned a variety of techniques to offer protection to the transplanted organs during aneurysm repair such as cold perfusion, shunting, temporary surgical bypass and extracorporeal circuits etc. Critical review of these adjuncts seems to suggest that that they do not give any better results than just using a “clamp and go” approach. Endovascular aneurysm repair (EVAR) may offer some advantages for transplant patients who have suitable anatomy for endovascular stent deployment. In addition to these surgical techniques, various aspects of medical management for renal, cardiac and hepatic transplant recipients undergoing AAA repair are discussed.

Evaluation of A-V Impulse Technology as a Treatment for Oedema Following Polytetrafluoroethylene Femoropopliteal Surgery in a Randomised Controlled Trial - Corrected Proof

2010-08-05

Abstract: Objective: To investigate the efficacy of A-V impulse technology (A-V) for oedema prevention and treatment following PTFE femoropopliteal surgery.Design: Prospective randomized clinical trial.Materials: 36 patients undergoing PTFE femoropopliteal bypass reconstructions, either being treated postoperatively with a compression stocking (CS) (Group-1, n = 19) or with A-V (Group-2, n = 17).Methods: Patients in treatment group-1 used a CS postoperatively during 1 week day and night, patients in group-2 were treated with A-V postoperatively at night during one week. The lower leg circumference was measured preoperatively and at five postoperative time points.Results: Limb circumference has increased postoperatively on day 1 (CS 1.5%/A-V 1.4%), on day 4 (5.7%/6.3%), on day 7 (6.6%/6.1%), on day 14 (7.9%/7.7%) and on day 90 (5.8%/5.2%). Differences between treatment groups were not significant. A re-operation gives a significant 3.9% increase in circumference as compared to a first operation (95% CI: 1.5–6.4%; p = 0.002).Conclusion: No significant differences were found in the extent of developed edema between the groups following PTFE femoropopliteal bypass surgery. A redo peripheral bypass operation results in significantly more postoperative oedema than a first-time performed bypass operation.

EVAR Technical Tip – Confirmation of Contralateral Limb Gate Cannulation Using a Moulding Balloon - Corrected Proof

W.R.W. Wilson, G.L. Benveniste — 2010-07-26

Introduction: Accurate confirmation of cannulation of the shorter contralateral limb gate of an abdominal aortic endograft can be challenging. Catheter angiogram may not exclude all possible errors.

Deep Vein Thrombosis (DVT) after Venous Thermoablation Techniques: Rates of Endovenous Heat-induced Thrombosis (EHIT) and Classical DVT after Radiofrequency and Endovenous Laser Ablation in a Single Centre - Corrected Proof

P. Marsh, B.A. Price, J. Holdstock, C. Harrison, M.S. Whiteley — 2010-07-23

Abstract: Introduction: Deep vein thrombosis (DVT) after varicose vein surgery is well recognised. Less well documented is endovenous heat-induced thrombosis (EHIT), thrombus extension into a deep vein after superficial venous thermoablation. We examined the rates of DVT in our unit after radiofrequency (RFA) and endovenous laser ablation (EVLA) with specific attention to thrombus type.Method: Retrospective analysis of all cases of RFA under general anaesthesia and EVLA under local anaesthesia was performed. Cases of DVT were identified from the unit database and analysed for procedural details.Results: In total, 2470 cases of RFA and 350 of EVLA were performed. Post-RFA, DVT was identified in 17 limbs (0.7%); 4 were EHIT (0.2%). Concomitant small saphenous vein (SSV) ligation and stripping was a risk factor for calf-DVT (OR 3.4, 95%CI 1.2–9.7, P=0.036), possibly due to an older patient group with more severe disease. Post-EVLA, 4 DVTs were identified (1%), of which 3 were EHIT (0.9%).Conclusion: The DVT rate including EHIT was similar in patients treated with RFA and EVLA and was low. Routine post-operative duplex ultrasound scanning is recommended until the significance of EHIT is better understood, in accordance with consensus guidelines. DVT rates for both techniques compare favourably with those published for saphenous vein stripping.

Part Two: Against the Motion - Corrected Proof

F.J. Veith — 2010-07-23

Keywords: Ruptured abdominal aneurysms, endovascular treatment, open repair, randomized trials, hypotensive hemostasis, balloon control, abdominal compartment syndrome Endovascular repair of a ruptured abdominal aortic aneurysm (RAAA) was first performed successfully by Marin, Veith et al. on April 21, 1994. Another case was first reported by Yusuf, Hopkinson et al. in 1994. Since then many centres have employed endovascular aneurysm repair (EVAR) to treat RAAAs with varying results. Several groups have developed standardised systems of management in the RAAA setting, have used EVAR whenever possible and have achieved good results with EVAR. In contrast other authors have used EVAR for RAAAs more selectively and have reported no better results with EVAR than with traditional open repair (OR).

Is There an Association between Angiotensin Converting Enzyme (ACE) Genotypes and Abdominal Aortic Aneurysm? - Corrected Proof

2010-07-23

Abstract: Objectives: There is strong evidence of a genetic predisposition to abdominal aortic aneurysm (AAA), however the genes involved remain largely elusive. Recently, two large studies have suggested an association between the angiotensin converting enzyme gene and AAA. This study aimed to investigate the possible association between the ACE insertion/deletion polymorphism and abdominal aortic aneurysm (AAA) in order to replicate the findings of other authors.Design and Methods: A case-control study was performed including 1155 patients with aneurysms and 996 screened control subjects. DNA was extracted from whole blood and genotypes determined in 1155 AAAs and 996 controls using a two stage polymerase chain reaction (PCR) technique.Results: The groups were reasonably matched in terms of risk factors for AAA. No association was found between the ACE gene insertion/deletion polymorphism and AAA in this study.Conclusions: This study cannot support the findings of previous authors and provides evidence against a link between the ACE gene insertion/deletion polymorphism and AAA.

Heterogeneity of Reporting Standards in Randomised Clinical Trials of Endovenous Interventions for Varicose Veins - Corrected Proof

B. Thakur, J. Shalhoub, A.M. Hill, M.S. Gohel, A.H. Davies — 2010-07-23

Abstract: Aims: The efficacy of endovenous treatments for venous reflux has been demonstrated in numerous randomised clinical trials, although significant heterogeneity may exist between studies. The aim of this study was to assess the heterogeneity in reporting between randomised clinical trials investigating endovenous treatments for patients with varicose veins.Methods: A literature search of the Pubmed, Cochrane and Google Scholar databases was performed using appropriate search terms. Randomised clinical trials published between January 1968 and June 2009 evaluating endovenous interventions for varicose veins were included and relevant abstracts and full text articles were reviewed. Published study reports were evaluated against recommended reporting standards published by the American Venous Forum in 2007.Results: Twenty-eight randomised trials fulfilled the inclusion criteria. Median patient age (reported in 20/28 studies) ranged from 33 to 54 years. The CEAP classification was presented in 17/28 studies and the proportion of patients with C2 disease ranged from 6.3% to 83.5%. A total of 31 different outcome measures were utilised. This included 13 different questionnaires, varicose vein recurrence at 38 time points and 30 categories of complications. Duplex ultrasonography was used in 21/28 trials to assess recurrence. Quality of life was only evaluated in 11 studies and the follow-up period ranged from 3 weeks to 10 years.Conclusions: Meaningful comparison across randomised studies of endovenous treatments is made difficult by considerable variations in study populations and outcome measures between trials. This highlights the need for the use of prospectively agreed population selection, and reporting standards for outcome measures in randomised clinical assessments of new treatments.

The Efficacy of a New Stimulation Technology to Increase Venous Flow and Prevent Venous Stasis - Corrected Proof

M. Griffin, A.N. Nicolaides, D. Bond, G. Geroulakos, E. Kalodiki — 2010-07-23

Abstract: Objectives: Electrical stimulation of calf muscles has been shown to be effective in prevention of DVT. The aim was to determine: (a) dependence of venous blood velocity and ejected volume on the rates of stimulated calf contractions: (b) clinical factors affecting efficacy in healthy individuals.Methods: The maximum intensity stimulus tolerated was applied to calfs of 24 volunteers. In popliteal veins, Peak Systolic Velocities (PSV), ejected volume per individual stimulus (Stroke Volume SV) and ejected Total Volume Flow per minute (TVF) of expelled blood were determined using ultrasound. Stimulation rates from 2 to 120 Beats Per Minute (bpm) were applied.Results: Mean baseline popliteal PSV was 10 cm/s. For stimulation rates between 2 and 8 bpm, the PSV was 10 times higher and reached 96–105 cm/s. Stroke volume (SV) per individual stimulus decreased in a similar fashion. With increasing rates of stimulation the TVF increased by a factor of 12 times (from 20 ml/min to 240 ml/min).Conclusion: Electrical stimulation is an effective method of activating the calf muscle pump. Enhancements of popliteal blood velocity and volume flow are key factors in the prevention of venous stasis and DVT. Further studies are justified to determine the stimulation rates in those with a compromised venous system.

No Effect of Melatonin to Modify Surgical-Stress Response after Major Vascular Surgery: A Randomised Placebo-controlled trial - Corrected Proof

2010-07-20

Abstract: Background: A possible mechanism underlying cardiovascular morbidity after major vascular surgery may be the perioperative ischaemia–reperfusion with excessive oxygen-derived free-radical production and increased levels of circulating inflammatory mediators. We examined the effect of melatonin infusion during surgery and oral melatonin treatment for 3 days after surgery on biochemical markers of oxidative and inflammatory stress.Methods: Patients received an intra-operative intravenous infusion of 50 mg melatonin or placebo. In addition, all patients received 10 mg melatonin or placebo orally the first 3 nights after surgery. Blood samples for analysis of malondialdehyde (MDA), ascorbic acid (AA), dehydroascorbic acid (DHA) and C-reactive protein (CRP) were collected preoperatively, and at 5 min, 6 h and 24 h after clamp removal (recirculation of the first leg).Results: Twenty-six patients received melatonin and 24 patients received placebo. No significant differences were observed in any of the oxidative and inflammatory stress parameters. There were significantly more side effects in the melatonin group than in the placebo group.Conclusions: Melatonin treatment in the perioperative period did not reduce the oxidative and inflammatory parameters measured in this study.

Comments regarding ‘Personalised Predictions of Endovascular Aneurysm Repair Success Rates: Validating the ERA Model with UK Vascular Institute Data’ - Corrected Proof

Dink A. Legemate — 2010-07-12

This important paper externally validates the ERA Model. The model has the potential to improve the care for patients who are considered for endovascular aneurysm repair. For most readers of the journal this is a quite theoretical paper, which is often a reason to take the conclusion for granted, without any further implementation in personal practice. Is this right? When I reviewed the paper I immediately felt that I had to take good notice of the content as the successful external validation of a prediction model might have consequences for my decision making and the informed consent procedure with my patients. The ERA Model provides more extensive information than previous prediction models (e.g. GAS) as besides perioperative mortality and morbidity, it also predicts technical failures, the need for reintervention and long term survival.

Hybrid (Open and Endovascular) Repair of Distal Extra-cranial Internal Carotid Artery Aneurysm - Corrected Proof

E. Wong, W.-L. Chue — 2010-07-09

This paper describes a hybrid repair of a distal extra-cranial internal carotid artery aneurysm involving open surgical transposition of the internal carotid artery followed by endovascular stent graft repair of the aneurysm. This procedure is most useful in cases with challenging anatomy to enable repair of the internal carotid artery aneurysm with minimal morbidity to the patient.

Response to comments of Prof. M.J. Gough Concerning SCAMICOS - Corrected Proof

F. Lundgren — 2010-07-09

In response to Professor M.J. Gough’s invited commentary of our article we want to emphasise some further aspects concerning patency and limb salvage in relation to the vein collar anastomosis technique. Only one (not several) randomised clinical trial – with two publications – has previously reported patency and limb salvage with vein collar at the distal anastomosis of a PTFE-bypass. In that study from the Joint Vascular Research Group – JVRG, only 15 patients with a bypass to the crural vessels were randomised, and there was no difference in one-year primary patency rate in this group between vein collar and no vein collar patients. In the second report these 15 patients appear to have been excluded together with five additional patients with bypass to the below-knee popliteal artery, which makes it difficult to evaluate. In addition, conflicting information with respect to patency rate is given in the text and illustrations and the statistical hypothesis testing appears to have been done on selected parts of the follow-up and not on all available data.

Validation of a Fully Automatic Photoplethysmographic Device for Toe Blood Pressure Measurement - Corrected Proof

2010-07-09

Abstract: Objectives: This study was designed to assess the accuracy and reliability of a new, portable, fully automated photoplethysmography (PPG) device for toe blood pressure (TBP) measurement.Design: Within-subject comparison with conventional laser Doppler (LD) measurement.Materials and methods: Four TBP measurements were performed on both lower limbs, alternatively with LD and PPG in 200 patients recruited at the Nîmes University Hospital. Reproducibility was assessed by the intraclass correlation coefficient (ICC). The concordance between the two methods was evaluated by Lin’s concordance correlation coefficient (CCC), in the whole population as well as in comorbidity subgroups. A potential bias was investigated with the Bland and Altman method.Results: The ICC was 0.887 (95% confidence interval (CI) 0.852–0.913) and 0.893 (0.860–0.918) on the right side (n = 193), 0.905 (0.875–0.928) and 0.898 (0.866–0.922) on the left side (n = 188) for PPG and LD measurements, respectively. The CCC was 0.913 (0.885–0.934) on the right side and 0.915 (0.888–0.937) on the left side, and remained >0.8 regardless of co-morbidities.Conclusions: This new, fully automatic, photoplethysmographic device yielded reliable TBP measurements and showed good agreement with the reference LD system over a wide range of values.

Upper-Limb Thrombo-Embolectomy: National Cohort Study in Denmark - Corrected Proof

2010-07-09

Abstract: Objectives: We investigated the incidence of thrombo-embolectomy in upper-limb and prognosis with respect to arm amputation, stroke and death.Methods: We performed a national cohort study of individuals, aged 40–99 years, and undergoing first-time thrombo-embolectomy in the brachial, ulnar or radial artery in Denmark from 1990 to 2002. The data were retrieved from the National Vascular Registry and from the National Registry of Patients and the Civil Registration System. Patients were followed until 2006 to ascertain the occurrence of amputation and stroke and until 2007 with respect to death.Results: In total, 1377 incident cases of thrombo-embolectomy were registered, comprising 504 (36.6%) males with a mean age of 72.0 (standard deviation (SD) 12.4) years and 873 (63.4%) females with a mean age of 77.2 (SD 11.7) years. Incidence was 3.3 (95% confidence interval (CI): 3.1–3.7) for males and 5.2 (95% CI: 4.9–5.6) for females per 100000 person-years. After thrombo-embolectomy, upper-limb amputation was performed in 11 (incidence 2.2%; 95% CI: 1.2–3.4) males and 31 (3.6%; 95% CI: 2.5–4.9) females. Age- and sex-specific risk of stroke was 2–16 times higher, and risk of death 3–11 times higher, than in the general population.Conclusions: Upper-limb thrombo-embolectomy is associated with an increased risk of limb amputation, stroke and death.

Comment on “Endovascular Stent-graft Placement in Stanford Type B Aortic Dissection in China” - Corrected Proof

J. Xiong, W. Guo, X.P. Liu — 2010-07-09

We thank Drs Chang and Li for their efforts to review the Chinese data on type B dissection by endovascular stenting. Coincidently we also accomplished a similar review, and we would like to add our comments with regard to the following aspects of their study:

Duplex Ultrasound Scanning of Peripheral Arterial Disease of the Lower Limb - Corrected Proof

J.P. Eiberg, J.B. Grønvall Rasmussen, M.A. Hansen, T.V. Schroeder — 2010-07-07

Abstract: Objectives: To assess the reliability and applicability of duplex ultrasound scanning (DUS) of lower limb arteries, compared with digital subtraction angiography (DSA), in patients with peripheral arterial disease (PAD).Design: A prospective, blinded, comparative study.Materials and methods: A total of 169 patients were examined by DUS and DSA. Intermittent claudication (IC) was present in 42 (25%) patients and critical limb ischaemia (CLI) in 127 (75%) patients. To allow segment-to-segment comparison, the arterial tree was divided into 15 segments. In total, 2535 segments were examined using kappa (κ) statistics to test the agreement.Results: The agreement between DUS and DSA was very good (κ>0.8) or good (0.8≥κ>0.6) in most segments, but moderate (0.6≥κ>0.4) in the tibio-peroneal trunk and the peroneal artery. Agreement between the two techniques was significantly better in the supragenicular (κ=0.75 (95% confidence interval (CI): 0.70–0.80)) than in the infragenicular segments (κ=0.63 (0.59–0.67)) (p<0.001). Similarly, the technical success rate was significantly higher in the supragenicular segments (DUS: 100%; DSA: 99%) than in the infragenicular segments (both 93%) (p<0.001). DUS was the best technique for imaging of the distal crural arteries (92% vs. 97%; p<0.001) and DSA was the best technique for imaging of the proximal crural arteries (95% vs. 91%; p<0.01). Neither the agreement nor the technical success rate was influenced by the severity of PAD, that is, IC versus CLI.Conclusion: The agreement between DUS and DSA was generally good, irrespective of the severity of ischaemia. DUS performed better in the supragenicular arteries than in the infragenicular arteries. However, DUS compared favourably with DSA in both tibial vessels, particularly in the distal part, which makes DUS a useful non-invasive alternative to DSA.

Personalised Predictions of Endovascular Aneurysm Repair Success Rates: Validating the ERA Model with UK Vascular Institute Data - Corrected Proof

M. Barnes, M. Boult, M.M. Thompson, P.J. Holt, R.A. Fitridge — 2010-07-05

Abstract: Objective: The objective of this study was to externally validate the existing Australian Endovascular aneurysm repair Risk Assessment (ERA) Model using data from a major vascular centre in the United Kingdom.Methods: Data collected from 312 endovascular abdominal aortic aneurysm repair patients at St George’s Vascular Institute, London, UK were fitted to the ERA Model.Results: Despite St George’s patients being sicker (p < 0.001), having larger aneurysms (p < 0.001) and being more likely to die (p < 0.05) than the Australian patients, their data fitted the ERA Model well for the risk factors early death, aneurysm-related death, three-year survival and type I endoleaks as evidenced by higher area under ROC curves and/or higher R2 goodness of fit statistics than the Australian data.Conclusions: The first external validation of the ERA Model using data from St George’s Vascular Institute suggests that this tool can be used in different countries and hospital settings. The authors believe the ERA Model is robust and allows valid personalised predictions of outcomes by surgeons treating routine aneurysms as well as those in tertiary referral practices with more adverse outcomes.

Inhibitory Effect of TIMP Influences the Morphology of Varicose Veins - Corrected Proof

2010-07-05

Abstract: Objectives: Imbalance of matrix metalloproteinase enzymes (MMP) and their inhibitors (TIMPs) may contribute to the development of varicose veins. We hypothesised that, histological changes in varicose vein wall correlate with alterations in expression of MMP/TIMP.Methods: Varicose veins (n = 26) were compared with great saphenous vein (GSV) segments (n = 11) from arterial bypass, and with arm and neck veins from fistula and carotid operations (n = 13). Varicose vein wall thickness was measured, enabling categorisation as atrophic and hypertrophic. MMP-2, MT1-MMP, TIMP-2, and TIMP-3 expression were quantitatively analysed by immunohistochemistry.Results: There was significantly higher expression of TIMP-2 (immunopositive area 4.34% versus 0.26%), linked with connective tissue accumulation in the tunica media of varicose veins as compared with arm and neck vein controls. TIMP-2 and TIMP-3 expression was higher in hypertrophic than atrophic segments (3.2% versus 0.99% for TIMP-2, 1.7% versus 0.08% for TIMP-3). Similarly, TIMP-2 and TIMP-3 had elevated expression in the thicker proximal varicose vein segments compared to distal (4.3% versus 1.3% for TIMP-2 and 0.94% versus 0.41% for TIMP-3).Conclusions: This study linked morphological changes in varicose vein walls with MMP/TIMP balance. A higher TIMP expression favours deposition of connective tissue and thus thicker vein wall, reducing matrix turnover by suppression of protease activity.

Aortic Length Changes During Abdominal Aortic Aneurysm Formation, Expansion and Stabilisation in a Rat Model - Corrected Proof

2010-06-16

Abstract: Background: Determinants of extracellular matrix (ECM) destruction/reconstruction balance influencing abdominal aortic aneurysm (AAA) diameter may impact length.Objective: Document aortic lengthening, its correlation to diameter, and determine how treatments that impact diameter also affect length.Methods: Three hundred and fifty-five diameter and length measurements were performed in 308 rats during AAA formation, expansion and stabilisation in guinea pig aortas xenografted in rats. Impact of modulation of ECM destructive/reconstructive balance by endovascular Vascular Smooth Muscle Cell (VSMCs) seeding, TIMP-1, PAI-1 and TGF-beta1 overexpression on length has been assessed.Results: Length increased in correlation with diameter during formation (correlation coefficient (cc): 0.584, P<0.0001) and expansion (cc: 0.352, P=0.0055) of AAAs. Overexpression of TIMP-1 and PAI-1 decreased lengthening (P=0.02 and 0.014, respectively) demonstrating that elongation is driven by matrix metalloproteinases and their activation by the plasmin pathway. Overexpression of TGF-beta1 controlled length in formed AAAs (17.3±9.6 vs. 5.9±7.4mm, P=0.022), but not VSMC seeding, although both therapies efficiently prevented further diameter increase. Length and diameter correlation was lost after biotherapies.Conclusion: Length increases in correlation with diameter during AAA formation and expansion, as a consequence of ECM injury driven by MMPs activated by the plasmin pathway. Correlation between length and diameter increases is not universally preserved.

Predictive Factors for In-stent Restenosis after Balloon-mounted Stent Placement for Symptomatic Intracranial Atherosclerosis - Corrected Proof

2010-06-16

Abstract: Objectives: We sought to evaluate whether clinical, lesion-related and procedural factors may predict in-stent restenosis (ISR) after intracranial stenting.Methods: Sixty-one Chinese patients with 65 lesions treated with single bare metal balloon-mounted stent for symptomatic intracranial arterial stenosis underwent conventional angiographic follow-up after procedures between March 2004 and July 2009. Clinical, lesion-related and procedural factors were analysed for any predictive power for the ISR using univariate and multivariate analysis. ISR was defined as >50% stenosis within or at the edge of the stent or absolute luminal loss >20%.Results: ISR was found in 18 patients (18/61, 29.5%) with 20 lesions (20/65, 30.8%) at a median follow-up of 7 months (range, 5–30 months). Univariate analysis revealed that diabetes, Mori classification, lesion length and stent diameter were associated with ISR. In addition, diabetes (hazard ratio (HR), 2.661; 95% confidence interval (CI), 1.044–6.787; P=0.040) and lesion length (HR, 1.206; 95% CI, 1.023–1.421; P=0.026) were detected as two independent predictors for ISR by stepwise multivariate Cox regression analysis.Conclusions: ISR after intracranial stenting with bare metal balloon-mounted stents in our series seems to be more frequent than those reported by the majority of the published case series. Diabetes and lesion length are associated with increased risk of ISR.

Evidence that Statins Protect Renal Function During Endovascular Repair of AAAs - Corrected Proof

K.G. Moulakakis, V. Matoussevitch, A. Borgonio, M. Gawenda, J. Brunkwall — 2010-06-14

Abstract: Objectives: Several studies have documented a slight but significant deterioration of renal function after endovascular repair of abdominal aortic aneurysm (AAA) (EVAR). The aim of this retrospective study was therefore to investigate whether medication with statins may favourably affect perioperative renal function.Material and Methods: From January 2000 to January 2008, out of a total cohort of 287 elective patients receiving endovascular repair of their AAA or aortoiliac aneurysm, 127 patients were included in the present study, as their medication was reliably retrievable. Patients were divided according to whether their medication included statins (>3 months). Second, they were subdivided according to their supra- (SR) or infrarenal (IR) endograft fixation. Serum creatinine (SCr) and creatinine (CrCl) clearance were determined preoperatively, postoperatively, at 6 and 12 months. Patients with known pre-existing renal disease, with incorrect placement of the stent graft resulting in severe renal artery stenosis, and with occlusion or renal parenchymal infarction were excluded from the study.Results: Patients receiving an infrarenal fixation of their graft had no change in the renal function, regardless whether they were on statins or not. In patients with SR fixation not receiving statins, a deterioration in renal function was observed in the early postoperative period ((SCr) preoperative vs. SCr postoperative: 1.02±0.2 vs. 1.11±0.28, p<0.001 and (Cr.Cl) preoperative vs. Cr.Cl postoperative: 74.1±21.4 vs. 68.0±21.4, p<0.001), whereas patients on statins experienced no change in renal function (SCr preoperative vs. SCr postoperative: 0.99±0.24 vs. 1.02±0.20n.s. and Cr.Cl preop vs. Cr.Clpostop.: 76.4±19.1 vs. 74.28±20.50, n.s.). During follow-up, a constant worsening of renal function at 6 and 12 months was observed, irrespective of the medication with statins.Conclusions: The present study suggests a slight immediate deterioration of the renal function using (SR) fixation, and this could be prevented by the use of statins. During follow-up, statins did not protect from further renal deterioration. Broader studies are needed to confirm a definitive relation between statin use and renal protection during the endovascular repair of AAA.