One hundred vascular surgery citation "classics" from the surgical literature.

J Vasc Surg. 2010 Aug 27;

Authors: O'Connor DJ, Gargiulo NJ, Scher LA, Jang J, Lipsitz EC

PMID: 20801612 [PubMed - as supplied by publisher]

Clinical applications of robotic technology in vascular and endovascular surgery.

J Vasc Surg. 2010 Aug 27;

Authors: Antoniou GA, Riga CV, Mayer EK, Cheshire NJ, Bicknell CD

BACKGROUND:: Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery. METHODS:: A systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords "surgical robotics," "robotic surgery," "robotics," "computer assisted surgery," and "vascular surgery" or "endovascular" for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken. RESULTS:: Seventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited. CONCLUSIONS:: Robotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery.

PMID: 20801611 [PubMed - as supplied by publisher]

Outcomes before and after initiation of an acute aortic treatment center.

J Vasc Surg. 2010 Aug 27;

Authors: Davies MG, Younes HK, Harris PW, Masud F, Croft BA, Reardon MJ, Lumsden AB

BACKGROUND:: Acute aortic syndromes remain life-threatening. Time is of the essence, as mortality rises with increasing time after the acute episode. The aim of this report is to show changes in practice and outcomes after the establishment of an acute aortic treatment center (AATC) to expedite the care of acute aortic syndromes in a major metropolitan area with the belief that "door to intervention time under 90 minutes" reduces mortality and morbidity from acute aortic disease. METHODS:: A database of patients admitted with acute aortic disease (Type A and B aortic dissections, acute thoraco-abdominal aortic aneurysms, acute and ruptured abdominal aortic aneurysms) for 1 year prior to initiation (2007) and 1 year after initiation of the pathway (AATC) in 2008 was developed. Comorbidities were scored according to Society of Vascular Surgery criteria. Anatomic and functional outcomes were determined and categorized by Society of Vascular Surgery reporting criteria. Multivariate analysis was performed for categorical outcomes and Cox proportional hazard analyses for time-dependent outcomes. RESULTS:: Six hundred twenty-one patients reported with aortic disease to the cardiovascular services; 306 patients were considered to have acute disease. When compared with the year before the AATC was instituted, there was a 30% increase in the total number of admissions and a 25% increase in acute pathology after setting up the AATC (P = .02). There was a two-fold increase in thoracic aortic dissections admitted to the service. Initiation of the treatment pathway resulted in a highly significant 64% reduction in time to definitive therapy (526 +/- 557 vs 187 +/- 258 minutes, mean +/- SD pre-AATC vs AATC; P = .0001). Comorbidity scores were equivalent between the two cohorts. Despite the increase in acuity, mortality (4% vs 6%) and morbidity (41% vs 45%) rates were unchanged, and there was a significant decrease in intensive care unit length of stay (5 vs 4 days, pre-AATC cohort vs the AATC cohort), but total hospital length of stay (11 vs 10 days) was unchanged. There was no correlation between deaths within 30 days and length of stay in the intensive care unit. CONCLUSION:: Establishment of a multidisciplinary AATC pathway was associated with a 30% increase in volume, 64% reduction in time to definitive treatment, improved throughput with reduced intensive care unit time, and maintained clinical efficacy despite an increase in acute admissions. These results suggest the concept be further evaluated.

PMID: 20801610 [PubMed - as supplied by publisher]

Eight-year experience with carotid artery stenting for correction of symptomatic and asymptomatic post-endarterectomy defects.

J Vasc Surg. 2010 Aug 27;

Authors: Marone EM, Coppi G, Tshomba Y, Chiesa R

BACKGROUND:: Carotid endarterectomy (CEA) has been shown to be superior to medical therapy alone in the prevention of stroke only if it can be safely performed (ie, with a complication rate less than 3% in asymptomatic patients and less than 6% in symptomatic patients). Technical defects are the most common cause of neurological complications after CEA, and their correction has traditionally been performed through standard surgical techniques. METHODS:: From 1999, we started to treat intimal flaps, dissection, or partial thrombosis after CEA with carotid artery stenting (CAS). A retrospective analysis of the operating room registry and of the registry of our Interventional Cardiology laboratory was conducted in order to identify all the patients that underwent stenting of the internal carotid artery after CEA between January 2001 and June 2009. RESULTS:: During the time period considered, 5012 CEA were performed at our institution and a total of 34 patients (34/5012; 0.6%) were found to have received carotid stenting after CEA, both for symptomatic and asymptomatic defects. Immediate technical success was obtained in all patients. One major cerebrovascular adverse event (1/34; 3%) in the immediate perioperative period was recorded. At a mean follow-up of 18.6 months (range, 3-84 months; median, 12 months), we did not observe any neurological symptoms related to the treated carotid artery, nor hemodynamic in-stent restenosis. Long-term follow-up (ie, equal or greater than 4 years) was available for five patients: all patients remained event-free during the entire period. CONCLUSIONS:: Our study adds to the assumption that CAS in post-CEA symptomatic and asymptomatic patients is safe and technically feasible, and represents a valid and quick alternative to standard surgical revision. Even if in a small group of patients, long-term results seem promising.

PMID: 20801609 [PubMed - as supplied by publisher]

Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up.

J Vasc Surg. 2010 Aug 27;

Authors: Christenson JT, Gueddi S, Gemayel G, Bounameaux H

BACKGROUND:: Endovenous laser therapy (EVLT) for ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity compared with high ligation and stripping (HL/S). Only a few randomized trials have reported early results. This prospective randomized trial compared EVLT (980 nm) and HL/S results at 1 and 2 years after the intervention. METHOD:: Patients with symptomatic varicose veins due to GSV insufficiency were randomized to HL/S (100 limbs) or EVLT (104 limbs). Four EVLT procedures failed primarily and were excluded. Phlebectomy and ligature of incompetent perforators were performed whenever indicated in both groups. Patients were re-examined clinically and by duplex ultrasound imaging preoperatively and at 12 days and at 1 and 2 years after treatment. Closure rate, complication rate, time to return to normal activity, the Aberdeen Varicose Vein Symptom Severity Score (AVVSS), the Varicose Venous Clinical Severity Score (VVCSS), and the Medical Outcome Study Short Form-36 scores were also recorded. RESULTS:: There were no differences in patient demographics, CEAP class, Widmer class, or severity scores between the groups. Simultaneous interventions did not differ between the groups. Similar times for the return to normal activity and scores for postoperative pain were reported. No major complications after treatment were recorded. HL/S limbs had significantly more postoperative hematomas than EVLT limbs, and EVLT patients reported more bruising. Follow-up at 1 year was 100% for HL/S and 99% for EVLT. Two GSVs in the EVLT group reopened and three partially reopened. No open GSVs occurred in HL/S limbs. Ninety-eight percent of the limbs in both groups were free of symptoms. VCSS, AVVSS, and Short Form-36 scores did not reveal any group differences. At 2 years, no differences compared with 1-year results were observed, except that two more GSVs in the EVLT group were partially reopened. CONCLUSIONS:: Abolition of GSV reflux and improvement in quality of life was similar after HL/S and EVLT. After EVLT, however, two GSVs were found completely reopened and five were partially reopened, which was significantly higher than after HL/S. A prolonged follow-up is ongoing.

PMID: 20801608 [PubMed - as supplied by publisher]

Endothelial cells are susceptible to rapid siRNA transfection and gene silencing ex vivo.

J Vasc Surg. 2010 Aug 27;

Authors: Andersen ND, Chopra A, Monahan TS, Malek JY, Jain M, Pradhan L, Ferran C, Logerfo FW

BACKGROUND:: Endothelial gene silencing via small interfering RNA (siRNA) transfection represents a promising strategy for the control of vascular disease. Here, we demonstrate endothelial gene silencing in human saphenous vein using three rapid siRNA transfection techniques amenable for use in the operating room. METHODS:: Control siRNA, Cy5 siRNA, or siRNA targeting glyceraldehyde-3-phosphate dehydrogenase (GAPDH) or endothelial specific nitric oxide synthase (eNOS) were applied to surplus human saphenous vein for 10 minutes by (i) soaking, (ii) applying 300 mm Hg hyperbaric pressure, or (iii) 120 mm Hg luminal distending pressure. Transfected vein segments were maintained in organ culture. siRNA delivery and gene silencing were assessed by tissue layer using confocal microscopy and immunohistochemistry. RESULTS:: Distending pressure transfection yielded the highest levels of endothelial siRNA delivery (22% pixels fluorescing) and gene silencing (60% GAPDH knockdown, 55% eNOS knockdown) as compared with hyperbaric (12% pixels fluorescing, 36% GAPDH knockdown, 30% eNOS knockdown) or non-pressurized transfections (10% pixels fluorescing, 30% GAPDH knockdown, 25% eNOS knockdown). Cumulative endothelial siRNA delivery (16% pixels fluorescing) and gene silencing (46% GAPDH knockdown) exceeded levels achieved in the media/adventitia (8% pixels fluorescing, 24% GAPDH knockdown) across all transfection methods. CONCLUSION:: Endothelial gene silencing is possible within the time frame and conditions of surgical application without the use of transfection reagents. The high sensitivity of endothelial cells to siRNA transfection marks the endothelium as a promising target of gene therapy in vascular disease. CLINICAL RELEVANCE:: Vein bypass graft failure due to intimal hyperplasia and re-stenosis continues to be an obstacle to long-term vein graft durability. Currently, there are no agents available that can be applied to vein grafts to reduce the rate of failure. This work demonstrates the feasibility of intraoperative siRNA therapeutics directed at the endothelium. If developed further, siRNA cocktails could be designed that provide a protective effect by silencing endothelial gene expression that leads to intimal hyperplasia. In addition, endothelial gene silencing could be used to induce favorable effects on the vasculature in other realms of vascular surgery.

PMID: 20801607 [PubMed - as supplied by publisher]

First United States experience of the TX2 Pro-Form thoracic delivery system.

J Vasc Surg. 2010 Aug 27;

Authors: Lee WA, Martin TD, Hess PJ, Beaver TM, Klodell CT

OBJECTIVES:: Failure to conform to the arch ("bird-beaking") can lead to endoleak and graft collapse after thoracic endovascular aortic repair (TEVAR). We report the first United States experience with the new TX2 Pro-Form (Cook Inc, Bloomington, Ind), a novel delivery system that became commercially available in October 2009, designed to enhance circumferential apposition of the TX2 thoracic endograft to the arch. METHODS:: This was a single-institution retrospective study. Endograft-to-arch conformance was quantitatively analyzed using intraoperative angiograms of consecutive, reverse chronologic cohorts of TX2 Pro-Form, TX2 Z-Trak (prior delivery system; Cook), and Gore TAG (W.L. Gore and Assoc, Flagstaff, Ariz). Only native aortic arch deployments in zones 2 and 3 were included. RESULTS:: During a 6-week period, 20 Pro-Form cases were performed, of which 17 patients met inclusion criteria. These were compared with 17 Z-Trak and 17 TAG patients. Endografts were successfully delivered to their intended proximal landing zones in all 51 patients. A higher proportion of dissections were treated in the Z-Trak (65%) and TAG (76%) patients (P = .03), but similar rates of zone 2/3 deployments (P = .30). Despite the mean arch angle being greatest for the Pro-Form patients (90 degrees vs 74 degrees vs 71 degrees , P = .18), the mean separation between the leading endograft edge and the aortic wall along the inner curvature of the arch was significantly less (1.4 vs 4.1 vs 5.7 mm; P = .0002), with complete apposition achieved in 65% of Pro-Form patients (18% Z-Trak, 6% TAG, P < .0001). This resulted in the lowest reduction in aortic luminal diameter at the proximal landing zone (5.5% vs 13.4% vs 19.3%; P = .0006) compared with Z-Trak and TAG. Rates of type Ia endoleak were similar (P = .38). CONCLUSIONS:: The Pro-Form delivery system significantly improves endograft conformation to the arch, resulting in minimum bird-beaking even in severely angulated anatomies.

PMID: 20801606 [PubMed - as supplied by publisher]

The effects of ginsenoside Rb1 on endothelial damage and ghrelin expression induced by hyperhomocysteine.

J Vasc Surg. 2010 Aug 27;

Authors: Xu Z, Lan T, Wu W, Wu Y

OBJECTIVE:: Studies have indicated that ginsenoside Rb1 and ghrelin could both prevent homocysteine (Hcy)-induced endothelial dysfunction through the endothelial nitric oxide synthase (eNOS)/nitric oxide (NO) mechanism. This study investigated whether endogenous ghrelin mediates the endothelial protection of ginsenosidee Rb1 through in vitro and in vivo experiments. METHODS:: Rats were randomized into a control group, a hyperhomocysteine (HHcy) model group with a high methionine diet, a ginsenosides (GS) group, and HHcy plus GS group. Plasma ghrelin was detected by enzyme-linked immunosorbent assay. Aortic rings for control and HHcy groups were treated with ghrelin or not. Endothelium-dependent vasodilatation function was evaluated by the aortic ring assay, and the structural changes were visualized by hematoxylin and eosin staining. Human umbilical vein endothelial cells (HUVECs) were cultured, and the experimental conditions were optimized according to NO production. After treatment, the NO, ghrelin, and von Willebrand factor (vWF) levels in the media were detected and analyzed with linear regression. Ghrelin and eNOS expression were observed by cell immunohistochemical staining. Ghrelin receptor antagonist was used to detect the mechanism of ginsenoside Rb1 on NO production, which was reflected by diacetylated 4,5-diaminofluorescein-2 diacetate fluorescence. RESULTS:: In vivo experiments demonstrated that plasma ghrelin levels in the HHcy group were significantly elevated vs controls (P < .05) and were significantly increased in the HHcy plus GS group (P < .01). Compared with control, endothelium-dependent vasodilatation function was greatly reduced in the HHcy group (P < .01), which was significantly increased in HHcy plus ghrelin group compared with HHcy group (P < .01). The arterial walls of HHcy group exhibited characteristic pathologic changes, which were repaired in HHcy plus ghrelin group. In vivo, compared with Hcy (200 muM) group, HUVECs pretreated with ginsenoside Rb1 (10 muM) for 30 minutes showed significant increases in NO and ghrelin levels and evident reduction in vWF levels. Linear regression analysis demonstrated that ghrelin levels were significantly positively correlated with NO levels and significantly negatively correlated with vWF levels. The addition of Rb1 to Hcy also greatly reversed Hcy-induced downregulation of ghrelin and eNOS expression. Ghrelin inhibition significantly abolished the upregulation of NO levels induced by Rb1. CONCLUSION:: Ghrelin can prevent Hcy-induced vascular endothelial dysfunction and structural damage. The compensatory elevation of plasma ghrelin levels in an Hcy-induced endothelial injury model may be a protective response. Ginsenoside Rb1 can significantly stimulate the ghrelin endocrine to inhibit endothelial injury. Ginsenoside also upregulates the NO signaling pathway reduced by Hcy through the ghrelin molecular mechanism.

PMID: 20801605 [PubMed - as supplied by publisher]

Proof-of-principle study of steam ablation as novel thermal therapy for saphenous varicose veins.

J Vasc Surg. 2010 Aug 27;

Authors: van den Bos RR, Milleret R, Neumann M, Nijsten T

INTRODUCTION:: During the last decade, thermal ablation techniques such as endovenous laser ablation have been challenging the position of traditional surgery for the treatment of saphenous varicose veins. The newest method of thermal ablation is pulsated steam, which works by heating the vein with steam at 120 degrees C. This study assessed the effectiveness of steam ablation of varicose veins in sheep and in humans. METHODS:: The safety of the procedure in sheep was assessed by cardiovascular monitoring during treatment. We used ultrasound imaging to examine occlusion of the veins. Changes in treated veins were examined microscopically. In a pilot study, 20 veins in 19 patients with insufficiency of the great or the small saphenous vein were treated with pulsated steam ablation. Anatomic success, patient satisfaction, and complications were investigated for 6 months after the procedure. RESULTS:: All veins in the sheep were occluded. No cardiovascular changes occurred during treatment. Histologic examination of treated veins showed typical changes of the vein wall, such as disappearance of the endothelial layer, fibrotic thrombosis, and major alterations in collagen fibers in the media. Steam ablation was effective in the 19 patients: 13 of 20 veins were completely closed, and 7 showed a very small segment of recanalization after 6 months of follow-up that did not seem to be clinically relevant. Nine patients had some ecchymoses at the puncture site, and one patient had a transient superficial phlebitis. A median maximal pain score of 1 (range, 0-10) was reported. No serious side effects, such as deep vein thrombosis, nerve injury, skin burns, or infections, were reported. Patients were very satisfied with the treatment, with a median satisfaction score of 9.25 (range, 0-10). CONCLUSIONS:: In this proof-of-principle study, pulsated steam ablation was an effective treatment for saphenous varicose veins.

PMID: 20801604 [PubMed - as supplied by publisher]

Spinal cord protection during thoracic endovascular aneurysm repair: Incidence, prevention, and management.

J Vasc Surg. 2010 Aug 27;

Authors: Rizvi AZ, Sullivan TM

PMID: 20801603 [PubMed - as supplied by publisher]

Thoracic aortic endovascular repair for mycotic aneurysms and fistulas.

J Vasc Surg. 2010 Aug 25;

Authors: Patel HJ, Williams DM, Upchurch GR, Dasika NL, Eliason JL, Deeb GM

Optimal medical therapy, in the setting of infections of the thoracic aorta (either native or prosthetic), is frequently associated with aortic-related mortality. Classic surgical teaching in this setting describes removal of all infected tissue with extra-anatomic bypass for aortic reconstruction. Several groups have described outcomes with aortic resection or graft explantation along with in situ grafting of the thoracic aorta. The patient population in whom this condition arises is often debilitated, elderly, immunocompromised, or has other comorbidity increasing the risk of open surgical intervention. In recognizing this clinical conundrum, several groups have suggested the use of endovascular technology as a potential less invasive solution. Long-term outcomes with this approach, however, remain ill defined. In 2008, we described outcomes for one of the largest series of infected thoracic aortic pathology (ITAP) treated with an endovascular approach. This report serves to update this series (now to include 27 patients treated since 1993) and review the experience as reported by others. Our results suggest that (1) the overall prognosis of the patient undergoing TEVAR is poor; (2) results with TEVAR for an infected prosthesis are worse than that for native aortic infection; and (3) the cause of mortality is often secondary to associated comorbid conditions rather than reinfection. TEVAR is therefore viewed as a palliative therapy in a high-risk cohort, but individual assessment is needed to determine whether it remains the definitive repair.

PMID: 20800423 [PubMed - as supplied by publisher]

Fenestrated and branched devices in the pipeline.

J Vasc Surg. 2010 Aug 25;

Authors: Greenberg RK, Qureshi M

A great deal of attention has been given to the use of endografts in anatomy that involves critical aortic branches, such as the visceral segment and the aortic arch. Hybrid techniques and other methods to preserve flow into such vessels have been met with questionable success. The recent publication of the endovascular aneurysm repair (EVAR) trial data, particularly their screening registry, indicates that the number of patients with aneurysms involving critical vessels is considerable compared with aneurysms with adequate infrarenal neck. This has renewed corporate interest in developing devices that will address these complex problems. Branches designed to preserve iliac flow, fenestrated and branched devices for the visceral aortic segment, and arch branch devices have all been used clinically with a variety of platforms. This article reviews the devices and treatment strategies that are being proposed or studied by both large and small companies.

PMID: 20800422 [PubMed - as supplied by publisher]

Starting a TEVAR practice: Required skills and interdisciplinary teams.

J Vasc Surg. 2010 Aug 25;

Authors: Starr J

Thoracic endovascular aortic repair (TEVAR) has become an accepted and often preferred approach to the management of patients with thoracic aortic disease. Advanced endovascular skills and specific credentialing criteria should be attained prior to establishing a TEVAR program. Individual practitioners may not possess all the required skills, making interdisciplinary collaboration crucial for a successful program. Learning curve analysis supports a strong endovascular background and knowledge of thoracic aortic diseases. Institutional support is critical when beginning a TEVAR program in the areas of training, imaging, supply management, and marketing. With all of the elements in place, a well-organized TEVAR program will succeed in providing vascular patients with exceptional care.

PMID: 20800421 [PubMed - as supplied by publisher]

Traumatic thoracic aortic injury and ruptures.

J Vasc Surg. 2010 Aug 25;

Authors: Tefera G

PMID: 20800420 [PubMed - as supplied by publisher]

Advanced thoracic endovascular aortic repair: Late complications of thoracic endografts.

J Vasc Surg. 2010 Aug 25;

Authors: Halandras P, Milner R

PMID: 20800419 [PubMed - as supplied by publisher]

Lymphatic malformation is a common component of Klippel-Trenaunay syndrome.

J Vasc Surg. 2010 Aug 25;

Authors: Liu NF, Lu Q, Yan ZX

OBJECTIVES:: Few previous studies have focused on the involvement of the lymphatic system in Klippel-Trenaunay syndrome (KTS), although some evidence suggests that lymphatic abnormalities are associated with the disease. The aim of the present study was to investigate the involvement of the lymphatic system in KTS. METHODS:: Magnetic resonance lymphangiography (MRL) with the use of gadobenate dimeglumine as the contrast was performed on 32 patients with KTS involving the extremities to evaluate lymphatic vessels, lymph nodes, and veins. RESULTS:: Thirty-one of 32 patients exhibited lymphatic vessel and/or lymph node anomalies, including hyperplasia (11/31), hypoplasia or aplasia (20/31) of lymphatic vessels, and lymphedema (31/31) of the affected limbs. Twenty-two patients showed asymmetry of the inguinal nodes exhibiting either the absence, or an increase or a decrease in number and size of the inguinal nodes. Venous dysplasia was found in 31 patients in superficial and/or deep veins. The results showed a high concomitance of malformations of the lymphatic system and veins in the affected limbs of patients with KTS. CONCLUSIONS:: Lymphatic system abnormalities as examined with MRL are commonly associated with KTS and are likely to play a significant role in the disorder.

PMID: 20800418 [PubMed - as supplied by publisher]

Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection.

J Vasc Surg. 2010 Aug 25;

Authors: Dong Z, Fu W, Wang Y, Wang C, Yan Z, Guo D, Xu X, Chen B

BACKGROUND:: Stent graft-induced new entry (SINE), defined as the new tear caused by the stent graft and excluding those arising from natural disease progression or iatrogenic injury from the endovascular manipulation, has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for Stanford type B dissection in our center. SINE appears to be remarkably life threatening. We investigated the incidence, mortality, causes, and preventions of SINE after TEVAR for Stanford type B dissection. METHODS:: Data for 22 patients with SINE were retrospectively collected and analyzed from 650 patients undergoing TEVAR for type B dissection from August 2000 to June 2008. An additional patient was referred to our center 14 months after TEVAR was performed in another hospital. The potential associations of SINE with Marfan syndrome, location of SINE and endograft placement, and the oversizing rate were analyzed by Fisher exact probability test or t test. RESULTS:: We found 24 SINE tears in 23 patients, including SINE at the proximal end of the endograft in 15, at the distal end in 7, and at both ends in 1. Six patients died. SINE incidence and mortality reached 3.4% and 26.1%, respectively. Two SINE patients were diagnosed with Marfan syndrome, whereas there were only 6 Marfan patients among the 651 patients. The 16 proximal SINEs were evidenced at the greater curve of the arch and caused retrograde type A dissection. The eight distal SINEs occurred at the dissected flap, and five caused enlarging aneurysm whereas three remained stable. The endograft was placed across the distal aortic arch during the primary TEVAR in all 23 patients. The incidence of SINE was 33.33% among Marfan patients vs 3.26% among non-Marfan patients (P = .016). There was no significant difference in mortality between proximal and distal SINE (25% vs 28.6%, P > .99), incidence of SINE between endograft placement across the arch and at the straight portion of descending thoracic aorta (23 of 613 vs 0 of 38, P = .39), and the oversizing rate between SINE and non-SINE patients (13% +/- 4.5% vs 16% +/- 6.5%, P = .98). CONCLUSIONS:: SINE appears not to be rare after TEVAR for type B dissection and is associated with substantial mortality. The stress yielded by the endograft seems to play a predominant role in its occurrence. It is important to take this stress-induced injury into account during both design and placement of the endograft.

PMID: 20800417 [PubMed - as supplied by publisher]

The middle-arm fistula as a valuable surgical approach in patients with end-stage renal disease.

J Vasc Surg. 2010 Aug 25;

Authors: Bonforte G, Rossi E, Auricchio S, Pogliani D, Mangano S, Mandolfo S, Galli F, Genovesi S

BACKGROUND:: American and European guidelines recommend the distal radial-cephalic fistula (dRCF) as the first and best hemodialysis access in patients with end-stage renal disease (ESRD). However, this kind of arteriovenous fistula (AVF) shows a limited primary unassisted patency and frequently needs surgical revisions or angiographic procedures, or both. When dRCF is not feasible, guidelines suggest a proximal brachiocephalic AVF. The middle-arm fistula (MAF), or autogenous forearm radial-median direct access, has been suggested as a possible alternative approach. This study evaluated MAF primary unassisted patency, the most frequent causes of MAF failure, and the possible related factors. METHODS:: Data on patients with a MAF placed from January 1991 until June 2008 were retrospectively collected. The probability of MAF failure overall and by the main subgroups was estimated according to Kaplan-Meier with Greenwood standard error (SE). Comparison of failure among different subgroups was performed using the log rank test in univariate analyses. The Cox regression model was used to investigate factors that independently affected the overall hazard of failure and cause-specific hazard of thrombosis. RESULTS:: At the end of follow-up, 14.0% of MAF failed (11.6% thrombosis, 1.7% stenosis, 0.7% failed maturation), and 44.2% of MAF were still working. Cumulative probability of MAF unassisted primary patency after 4 years from the creation was 79%. Univariate analyses highlighted that women (P = .019), underweight patients (P = .010), and MAF implantation after starting hemodialysis (P < .001) had a higher risk of MAF failure for any cause than men, normal and overweight patients, and MAF implanted before starting hemodialysis. Results of the Cox multivariate analysis for overall MAF failure confirmed that only MAF implantation before starting hemodialysis is a protective factor against any failure (P = .003), whereas female gender (P = .016) was associated with an increase of the thrombosis hazard ratio to 2.04 (95% confidence interval, 1.14-3.63). CONCLUSION:: Our data demonstrate that MAF has a good unassisted primary patency and suggest that this kind of AVF could be a valuable alternative surgical approach when dRCF is not feasible in ESRD patients.

PMID: 20800416 [PubMed - as supplied by publisher]

Long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep vein thrombosis in the TROMBOTEK trial.

J Vasc Surg. 2010 Aug 21;

Authors: Kurtoglu M, Koksoy C, Hasan E, Akcalı Y, Karabay O, Filizcan U,

OBJECTIVE: The present study was designed to evaluate the long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep venous thrombosis (DVT). METHODS: A total of 246 patients, comprising 128 men (mean age, 54.28 +/- 16.48 years) and 118 women (mean age, 50.11 +/- 16.47 years) with symptomatic lower extremity DVT, were included in this open-label, single-arm, multicenter, phase IV clinical trial conducted at 14 centers in Turkey. All patients were administered subcutaneous enoxaparin (1.5 mg/kg, once-daily) until international normalized ratio (INR) levels reached to 2 to 3, followed by oral warfarin (5 mg/d) for at least 3 months and elastic compression stockings (30-40 mm Hg). Clinical signs (leg circumference), symptoms (edema, pain, tenderness), recanalization rates upon duplex ultrasound examination, laboratory findings (D-dimer and INR levels), and postthrombotic syndrome status with CEAP classification were the efficacy parameters evaluated every 3 months during 18 months of follow-up. Safety end points included minor and major bleeding as well as serious adverse events. RESULTS: Ambulatory treatment with enoxaparin plus warfarin significantly reduced physical symptoms, including tenderness, edema, pain (P < .001), and the circumference of the affected leg (P < .001). The leg circumference difference in almost all patients was <1.5 cm at the end of 18 months (P < .001). Recanalization rates for occluded iliofemoral vein were 76.1% at 3 months and 86.5% at 18 months (P < .001). An early and significant decrease obtained in D-dimer levels on day 10 continued to decline significantly until month 6 and remained unchanged afterwards (P < .001). Of four patients diagnosed with major bleeding during oral anticoagulant use, three recovered with conservative treatment (reduction in hemoglobin levels in 2 developed at visit 2 [day 10] and intracranial bleeding in 1 developed at visit 3 [day 30]), and one patient required a hysterectomy after menorrhagia developed at visit 7 (month 18). Two of the 65 (9.9%) adverse events documented were serious adverse events, but none of the serious adverse events leading to death were related to the study medications. CONCLUSION: Ambulatory treatment with enoxaparin plus warfarin seems to be effective in symptomatic healing and in clinical improvement by reducing thrombus formation and organization at all levels of lower extremity venous system with DVT, without a significant major bleeding risk. Therefore, the results of our conventional conservative treatment are in line with 1A level evidence reported in the recent American College of Chest Physicians guideline.

PMID: 20732787 [PubMed - as supplied by publisher]

Endovascular management of type B aortic dissections.

J Vasc Surg. 2010 Aug 21;

Authors: Dimusto PD, Williams DM, Patel HJ, Trimarchi S, Eliason JL, Upchurch GR

PMID: 20732786 [PubMed - as supplied by publisher]