Finnvasc score and modified Prevent III score predict long-term outcome after infrainguinal surgical and endovascular revascularization for critical limb ischemia.

J Vasc Surg. 2010 Aug 13;

Authors: Arvela E, Söderström M, Korhonen M, Halmesmäki K, Albäck A, Lepäntalo M, Venermo M, Biancari F

BACKGROUND:: Estimation of the risk of adverse long-term outcome is of paramount importance in the treatment of critical limb ischemia (CLI). METHODS:: We evaluated the accuracy of two specific risk score systems, the Finnvasc score and the modified Prevent III (mPIII) score, in 1425 CLI patients who underwent unilateral, infrainguinal surgical (47.6%) or endovascular (52.4%) revascularization. The receiver operating characteristic (ROC) curve analysis was used to estimate the predictive value of these risk scoring methods. RESULTS:: The area under the ROC curve of Finnvasc score for prediction of 30-day amputation was 0.609 (95% confidence interval [CI] 0.549-0.677) and of mPIII score 0.533 (95% CI 0.457-0.609). The area under ROC curve of Finnvasc score for prediction of 30-day amputation-free survival was 0.622 (95% CI 0.573-0.671) and of mPIII score 0.588 (95% CI 0.533-0.642). The area under the ROC curve of Finnvasc score for prediction of 1-year amputation-free survival was 0.630 (95% CI 0.597-0.663, P < .0001) and of mPIII score 0.634 (95% CI 0.600-0.667, P < .0001). Finnvasc score predicted leg salvage (relative risk [RR] 1.431, 95% CI 1.319-1.551), survival (RR 1.233, 95% CI 1.116-1.363), and amputation-free survival (RR 1.422, 95% CI 1.319-1.534). mPIII score also predicted leg salvage (RR 1.190, 95% CI 1.108-1.277), survival (RR 1.245, 95% CI 1.193-1.300), and amputation-free survival (RR 1.223, 95% CI 1.176-1.272). CONCLUSIONS:: Finnvasc and modified PIII risk scoring methods predict long-term outcome of patients undergoing infrainguinal revascularization for CLI. Finnvasc score seems to perform well also in predicting immediate postoperative outcome.

PMID: 20709482 [PubMed - as supplied by publisher]

Outcomes in open repair of the thoracic and thoracoabdominal aorta.

J Vasc Surg. 2010 Aug 13;

Authors: Acher C, Wynn M

PMID: 20709481 [PubMed - as supplied by publisher]

Outcomes of planned celiac artery coverage during TEVAR.

J Vasc Surg. 2010 Aug 13;

Authors: Mehta M, Darling RC, Taggert JB, Roddy SP, Sternbach Y, Ozsvath KJ, Kreienberg PB, Paty PS

OBJECTIVE: Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA). METHODS: Since 2004, 228 patients underwent TEVAR under elective (n = 162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively. RESULTS: Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n = 20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n = 2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n = 3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair. CONCLUSIONS: Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed.

PMID: 20709480 [PubMed - as supplied by publisher]

Preface.

J Vasc Surg. 2010 Aug 7;

Authors: Matsumura JS

PMID: 20692798 [PubMed - as supplied by publisher]

Optimizing supervised exercise therapy for patients with intermittent claudication.

J Vasc Surg. 2010 Aug 7;

Authors: Nicolaï SP, Hendriks EJ, Prins MH, Teijink JA,

BACKGROUND:: The first-line intervention for intermittent claudication is usually supervised exercise therapy (SET). The literature describes a range of exercise programs varying in setting, duration, and content. The purpose of the present study was to examine the exercise protocols offered and to identify the impact of the intensity of the SET programs (in terms of frequency, duration, and type of exercise) on improvements in walking distance (response) in the first 3 months. The present study is part of the Exercise Therapy in Peripheral Arterial Disease (EXITPAD) study, a multicenter randomized clinical trial comparing the effects of SET provided by regional physiotherapists, with or without daily feedback, on the level of activities with the effects of walking advice. METHODS:: The analysis included patients randomized to receive SET with or without feedback. The physical therapists administering the SET were asked to fill out therapy evaluation sheets stating frequency, duration, and type of exercises. The relationship between training volume and the impact on walking distance was explored by dividing training volume data into tertiles and relating them to the median change in maximum walking distance at 3 and 12 months. RESULTS:: Data of 169 patients were included in the analysis. A SET program consisting of at least two training sessions per week each lasting over 30 minutes, during the first 3 months of a 1-year program tailored to individual patients' needs led to better results in terms of walking distance after 3 and 12 months than the other variants. The results of our analysis dividing training volume into tertiles suggest that there is a relationship between training volume and improvement in walking distance and that at least 590 minutes of training should be offered in the first 3 months. No differences were found between program involving only walking and a combination of exercises, nor between individual and group training. CONCLUSION:: A SET programs consisting of at least two training sessions a week, each lasting over 30 minutes, should be offered during the first 3 months of the SET program to optimize improvement in terms of maximum walking distance.

PMID: 20692797 [PubMed - as supplied by publisher]

Sourcing of superficial reflux in venous leg ulcers using duplex ultrasound.

J Vasc Surg. 2010 Aug 6;

Authors: Obermayer A, Garzon K

OBJECTIVE:: Mapping of venous reflux routes associated with medially or laterally located venous leg ulcers and their source of origin. METHODS:: This prospective report presents the results of duplex investigations performed in consecutive leg ulcer patients, all with venous reflux, in a time period over 2 years. A total of 169 patients (183 legs), with chronic venous leg ulcers (CEAP: C6) were examined in a private practice. The data collection integrated an examination that included medical history and clinical diagnoses and incorporated measurements such as body mass index, oscillometric index, and range of motion of the ankle joint. Venous function was assessed with duplex ultrasound, and the cases were described using the advanced CEAP classification. Additionally, a "sourcing" technique was performed with duplex ultrasound investigation of the ulcer bed and the venous system under manual compression and release of the ulcer. The principle of "sourcing" is to follow venous reflux from the ulcer area to its proximal origin. The detected reflux routes were classified either as "axial" or "crossover" type. RESULTS:: A total of 20% of the ulcer patients showed no clinically visible varicose veins. One hundred three patients had medial ulcers, 54 lateral ulcers, 21 medial and lateral, and five had gaiter ulcers. Sixty-four (35%) of the medially located ulcers had reflux in the great saphenous vein (GSV), 28 (15%) showed reflux in the medial perforating veins (axial types), and 11 (6%) had reflux in the small saphenous vein (SSV; crossover type). From 54 patients presenting with lateral ulcers, 25 (14%) showed GSV incompetence (crossover type) and only 13 (7%) SSV incompetence (axial type). Sixteen patients showed refluxes penetrating from deep into lateral perforating veins. CONCLUSION:: Crossover reflux routes were detected in 25 of 54 (46%) legs with lateral and in 11 of 103 (11%) legs with medial ulceration (chi(2) 44.34; P < .001). In venous ulcer patients, an extended examination (CEAP classification) and a special duplex technique ("sourcing") are recommended to identify the specific route responsible for the venous reflux. This seems essential for planning a rational treatment of venous reflux ulcers.

PMID: 20692796 [PubMed - as supplied by publisher]

Ellagic acid inhibits oxidized LDL-mediated LOX-1 expression, ROS generation, and inflammation in human endothelial cells.

J Vasc Surg. 2010 Aug 6;

Authors: Lee WJ, Ou HC, Hsu WC, Chou MM, Tseng JJ, Hsu SL, Tsai KL, Sheu WH

BACKGROUND: LOX-1, a lectin-like receptor on endothelial cells, facilitates the uptake of oxidized low-density lipoprotein (oxLDL). Expression of LOX-1 is involved in the pathobiological effects of oxLDL in endothelial cells, including reactive oxygen species (ROS) generation, suppression of endothelial nitric oxide synthase (eNOS) activity, and leukocytic adhesion. Moderate consumption of phenolic-enriched food may have a protective effect against the development of atherosclerosis via the antioxidant capacity of phenolic compounds at the endothelial level. In this study, we determined whether ellagic acid, a polyphenolic compound widely distributed in fruits and nuts, protects against oxLDL-induced endothelial dysfunction by modulating the LOX-1-mediated signaling pathway. METHODS: Human umbilical vein endothelial cells (HUVECs) were pretreated with ellagic acid at doses of 5, 10, 15, and 20 muM for 2 hours and then incubated with oxLDL (150 mug/mL) for an additional 24 hours. RESULTS: LOX-1 protein expression was markedly lower after exposure to oxLDL in HUVECs pretreated with ellagic acid or diphenyleneiodonium, a well-known inhibitor of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, than in HUVECs exposed to oxLDL alone, suggesting that ellagic acid deactivates NADPH oxidase. We also found that oxLDL activated the membrane assembly of p47(phox), Rac1, gp91 and p22(phox), and the subsequent induction of ROS generation; however, ROS generation was markedly suppressed in cells pretreated with ellagic acid or anti-LOX-1 monoclonal antibody. In addition, oxLDL down-regulated eNOS and up-regulated inducible NO synthase (iNOS), thereby augmenting the formation of NO and protein nitrosylation. Furthermore, oxLDL induced the phosphorylation of p38 mitogen-activated protein kinase, activated the NF-kappaB-mediated inflammatory signaling molecules interleukin-(IL) 6 and IL-8 and the adhesion molecules intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin, and stimulated the adherence of THP-1 (a human acute monocytic leukemia cell line) to HUVECs. Pretreatment with ellagic acid, however, exerted significant cytoprotective effects in all events. CONCLUSION: Findings from this study may provide insight into a possible molecular mechanism by which ellagic acid inhibits LOX-1-induced endothelial dysfunction. Our data indicate that ellagic acid exerts its protective effects by inhibiting NADPH oxidase-induced overproduction of superoxide, suppressing the release of NO by down-regulating iNOS, enhancing cellular antioxidant defenses, and attenuating oxLDL-induced LOX-1 up-regulation and eNOS down-regulation.

PMID: 20692795 [PubMed - as supplied by publisher]

Carotid artery stenting outcomes are equivalent to carotid endarterectomy outcomes for patients with post carotid endarterectomy stenosis.

J Vasc Surg. 2010 Aug 7;

Authors: Aburahma AF, Abu-Halimah S, Hass SM, Nanjundappa A, Stone PA, Mousa A, Lough E, Dean LS

BACKGROUND:: Carotid artery stenting (CAS) has been advocated as an alternative to redo surgery for patients with post-carotid endarterectomy (CEA) stenosis. This study compares early and late clinical outcomes for both groups. METHODS:: This study analyzes 192 patients: 72 had reoperation (Group A) and 120 had CAS for post-CEA stenosis (Group B). Patients were followed prospectively and had duplex ultrasounds at 1 month, and every 6 to 12 months thereafter. The perioperative complications (perioperative stroke, myocardial infarction/death, cranial nerve injury) and 4-year end points were analyzed. A Kaplan-Meier lifetable analysis was used to estimate rates of freedom from stroke, stroke-free survival, >/=50% restenosis, and >/=80% restenosis. RESULTS:: Demographic/clinical characteristics were comparable for both groups, except for diabetes mellitus and coronary artery disease, which were significantly higher in Group B. The indications for reoperations were transient ischemic attacks/stroke in 72% for Group A versus 57% for Group B (P = .0328). The mean follow-up was 33 months (range, 1-86 months) for Group A and 24 months (range, 1-78 months) for Group B (P = .0026). The proportion of early (<24 months) carotid restenosis prior to intervention was 51% in Group A versus 27% in Group B (P = .0013). The perioperative stroke rates were 3% and 1%, respectively (P = .5573). There were no myocardial infarctions or deaths in either group. The overall incidence of cranial nerve injury was 14% for Group A versus 0% for Group B (P < .0001). However, there was no statistical difference between the groups relating to permanent cranial nerve injury (1% versus 0%). The combined early and late stroke rates for Groups A and B were 3% and 2%, respectively (P = .6347). The stroke-free rates at 1, 2, 3, and 4 years for Groups A and B were 97%, 97%, 97%, and 97% and 98%, 98%, 98%, and 98%, respectively (P = .6490). The stroke-free survival rates were not significantly different. The rates of freedom from >/=50% restenosis at 1, 2, 3, and 4 years were 98%, 95%, 95%, and 95% for Group A versus 95%, 89%, 80%, and 72% for Group B (P = .0175). The freedom from >/=80% restenosis at 1, 2, 3, and 4 years for Groups A and B were 98%, 97%, 97%, and 97% versus 99%, 96%, 92%, and 87%, respectively (P = .2281). Four patients (one symptomatic) in Group B had reintervention for >/=80% restenosis. The rate of freedom from reintervention for Groups A and B were 100%, 100%, 100%, and 100% versus 94%, 89%, 83%, and 79%, respectively (P = .0634). CONCLUSIONS:: CAS is as safe as redo CEA. Redo CEA has a higher incidence of transient cranial nerve injury; however, CAS has a higher incidence of >/=50% in-stent restenosis.

PMID: 20692794 [PubMed - as supplied by publisher]

The Semmes Weinstein monofilament examination is a significant predictor of the risk of foot ulceration and amputation in patients with diabetes mellitus.

J Vasc Surg. 2010 Aug 7;

Authors: Feng Y, Schlösser FJ, Sumpio BE

OBJECTIVE: Diabetic peripheral neuropathy is a major complication of diabetes mellitus (DM) and is the leading cause of foot ulceration and lower extremity amputations (LEAs). The purpose of this systematic review is to evaluate current evidence regarding the prognostic value of the Semmes Weinstein monofilament examination (SWME) in predicting foot ulceration and LEA in patients with DM. METHODS: The MEDLINE/PubMed database was searched through November 2009 for articles pertaining to diabetic foot and SWME with no language or publication date restrictions. Prognostic studies with original data assessing the predictive value of SWME for foot ulceration or LEA in patients with DM were included in the selection. Data were systematically extracted and analyzed by two independent investigators. Absolute risks and relative risks were determined for each study. RESULTS: Of the 863 studies identified, nine articles were relevant, involving 11,007 patients with DM. Six studies were identified that assessed the prognostic value of SWME regarding diabetic foot ulceration. The relative risk for patients with a positive SWME result versus those with a negative result ranged from 2.5 (95% confidence interval [CI], 2.0 to 3.2) to 7.9 (95% CI, 4.4 to 14.3) in the identified studies with follow up between 1 and 4 years. Three of the studies assessed the risk of LEA with a positive SWME result. The relative risk for LEA ranged from 1.7 (95% CI, 1.1 to 2.6) to 15.1 (95% CI, 4.3 to 52.6) with follow-up between 1.5 and 3.3 years. CONCLUSIONS: All nine studies found SWME to be a significant and independent predictor of future foot ulceration or likely of future LEA as well in patients with DM. Therefore, SWME is an important evidence-based tool for predicting the prognosis of patients with diabetic foot, thus enabling improved patient selection for early intervention and management. More research should be conducted to elucidate the relationship between SWME and LEA.

PMID: 20692793 [PubMed - as supplied by publisher]

Spontaneous retroperitoneal hematoma associated with iliac vein rupture.

J Vasc Surg. 2010 Aug 7;

Authors: Jiang J, Ding X, Zhang G, Su Q, Wang Z, Hu S

OBJECTIVE: Spontaneous retroperitoneal hematoma (SRH) associated with iliac vein rupture is a rare but life-threatening emergency with high operative mortality. This study summarizes our experience in providing diagnostic and therapeutic management for this rare clinical entity. METHODS: Between May 2002 and May 2009, nine patients were admitted to our hospital for SRH and acute deep venous thrombosis (DVT). Medical data for demographics, clinical presentation, auxiliary examinations, treatment modalities, outcomes, and follow-up were retrospectively analyzed. RESULTS: Nine patients (8 women, 1 man) were enrolled in this study. All were aged >45 years (range, 46-70 years). The common clinical manifestations were sudden onset of left lower abdominal or lumbar pain, swelling of the left lower extremity, anemia, and hypotension. Most patients were diagnosed by duplex ultrasound imaging and computed tomography scan. Three patients were treated conservatively, and six underwent surgical or combined treatments, comprising 2 repairs of iliac vein, 1 iliac vein ligation and Palma-Dale bypass graft, 1 pelvic vein ligation, 1 removal of hematoma, and 1 repair of iliac vein, thrombectomy, and endovascular stent placement. The iliac vein ruptured in five patients. May-Thurner syndrome was found in three patients. One patient died after surgery (operative mortality, 16.7%). Postoperative morbidity was 50%. Mean volume of perioperative blood transfusion was 900 +/- 640 mL (range, 0-2000 mL). Mean lengths of stay were 2.7 +/- 1.4 days (range, 2-5 days) in the intensive care unit and 16.9 +/- 2.4 days (range, 14-21 days) in the hospital. Eight patients were postoperatively treated with 6 months of warfarin. Mean follow-up was 30.5 +/- 15.0 months (range, 6-50 months). The occurrence rate of chronic venous insufficiency was 87.5% during follow-up. CONCLUSIONS: SRH with concomitant DVT, especially in women aged >45, should be considered in patients with sudden lower abdominal or lumbar pain, leg swelling, anemia, and shock. Spontaneous iliac vein rupture and the presence of May-Thurner syndrome should be considered in these patients. Surgical interventions were associated with high mortality and morbidity. In our experience, conservative therapy was safer than open surgical procedures.

PMID: 20692792 [PubMed - as supplied by publisher]

Bioengineered vascular graft grown in the mouse peritoneal cavity.

J Vasc Surg. 2010 Aug 6;

Authors: Song L, Wang L, Shah PK, Chaux A, Sharifi BG

BACKGROUND:: We tested the hypothesis that the mouse peritoneum can function like a bioreactor to generate directed bio-engineered tissues such as those used for bypass grafting. Additionally, we reasoned that the mouse animal model would allow us to elucidate the underlying cellular and molecular mechanisms that are responsible for the generation of tissue in peritoneal cavity. METHODS:: Plastic tubes (two tubes/mouse) were implanted into the peritoneal cavity of three strains of mice (C57BL/6, BALB/c, and MRL). The tubes were harvested, tissue capsule surrounding the tubes was removed, and analyzed by immunostaining (five capsules/five mice/strain) and microarray (three capsules/three mice/strain). In addition, the tissue capsules that were harvested from MRL mice (n = 21) were grafted into abdominal aorta of the same mice as autografts. The patency of all grafts was monitored by micro-ultrasound, and their functionality was assessed by laser Doppler imaging of blood flow in femoral arteries. Venous (n = 13) and arterial isografts (n = 11) were used as positive controls. In a negative control group (five mice/strain), the abdominal aorta was occluded by double ligation with 9-0 silk. RESULTS:: The implanted plastic tubes required at least 8 weeks of incubation in the peritoneum of the three strains of mice in order to generate useful grafts. No vascular cells were found in the tissue capsules. Microarray analysis of tissue capsules revealed that the capsular cells express a gene expression program that is vastly shared among the three strains of mice, and the cells exhibit a high degree of plasticity. The micro-ultrasound analysis of the grafts showed that 62% of autografts remained patent compared with 77% of venous isografts and 91% of arterial isografts. The laser Doppler imaging analysis showed that blood flow dropped by 40% and 35% in the autografts and vein isografts, respectively, 1 day after surgery. The flow, however, rebounded to the level of arterial isografts 1 month post-surgery and remained unchanged among all grafts for the next 4 months. Immunostaining of the autografts showed a thick vessel wall with endothelial cells that lined the lumen and smooth muscle cells that constituted the graft wall. CONCLUSION:: The mouse peritoneal cavity of mice has the ability to function like a bioreactor to generate bio-engineered tissues. The tissue capsules harvested from peritoneal cavity of a mouse are composed of nonvascular cells that display phenotype of progenitor cells. After grafting, however, the capsule autografts become arterialized and remained patent for at least 4 months after surgery, similar to venous or arterial isografts.

PMID: 20692791 [PubMed - as supplied by publisher]

Gender differences in daily ambulatory activity patterns in patients with intermittent claudication.

J Vasc Surg. 2010 Aug 6;

Authors: Gardner AW, Parker DE, Montgomery PS, Khurana A, Ritti-Dias RM, Blevins SM

OBJECTIVES: To compare the pattern of daily ambulatory activity in men and women with intermittent claudication, and to determine whether calf muscle hemoglobin oxygen saturation (StO(2)) is associated with daily ambulatory activity. METHODS: Forty men and 41 women with peripheral arterial disease limited by intermittent claudication were assessed on their community-based ambulatory activity patterns for 1 week with an ankle-mounted step activity monitor and on calf muscle StO(2) during a treadmill test. RESULTS: Women had lower adjusted daily maximal cadence (mean +/- SE) for 5 continuous minutes of ambulation (26.2 +/- 1.2 strides/min vs 31.0 +/- 1.2 strides/min; P = .009), for 1 minute of ambulation (43.1 +/- 0.9 strides/min vs 47.2 +/- 0.9 strides/min; P = .004), and for intermittent ambulation determined by the peak activity index (26.3 +/- 1.2 strides/min vs 31.0 +/- 1.2 strides/min; P = .009). Women also had lower adjusted time to minimum calf muscle StO(2) during exercise (P = .048), which was positively associated with maximal cadence for 5 continuous minutes (r = 0.51; P < .01), maximal cadence for 1 minute (r = 0.42; P < .05), and peak activity index (r = 0.44; P < .05). These associations were not significant in men. CONCLUSION: Women with intermittent claudication ambulate slower in the community setting than men, particularly for short continuous durations of up to 5 minutes and during intermittent ambulation at peak cadences. Furthermore, the daily ambulatory cadences of women are correlated with their calf muscle StO(2) during exercise, as women who walk slower in the community setting reach their minimum calf muscle StO(2) sooner than those who walk at faster paces. Women with intermittent claudication should be encouraged to not only walk more on a daily basis, but to do so at a pace that is faster than their preferred speed.

PMID: 20692790 [PubMed - as supplied by publisher]

A comparaison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions.

J Vasc Surg. 2010 Aug 6;

Authors: Boufi M, Dona B, Orsini B, Auquier P, Hartung O, Alimi YS

OBJECTIVE: To assess the potential benefit of the addition of a covered stent to a subintimal recanalized artery in patients with femoro-popliteal occlusions. METHODS: From September 2003 to October 2005, we retrospectively analyzed all patients admitted for severe claudication or critical limb ischemia related to long femoro-popliteal occlusions and treated with subintimal recanalization. Patients were divided into two groups depending on whether they received a stent or not. All patients in the group treated with stent received a stent graft, and the entire length of the recanalized artery was covered in each case. Demographic data, indications, procedure, and outcomes were examined using survival analysis statistical techniques. RESULTS: Fifty-three patients (54 limbs) were treated consecutively for severe claudication (n = 19) or critical limb ischemia (n = 34). Thirty-four (64%) had a stent placed, while 19 (35.8%) did not. The mean length of the lesions treated was 20.11 cm (range, 5-35 cm). Statistically, there was no significant difference in lesion length, Rutherford stage of peripheral-artery disease, Transatlantic Inter-Society Consensus classification, and distal run-off between the two groups. The technical success rate was 94.5%, and two out of the three failures were treated with surgical bypass in one case and major amputation in the other. The third patient received only medical treatment. Combined procedures were required in the treatment of 68.2% of limbs in the no-stent group and 55.8% in the stent group. Mean follow up was 16.9 months (range, 1-35 months). At 1 year, primary, primary-assisted, and secondary patency for the stent vs no-stent groups was, respectively, 61.8% vs 78.9% (P = .49), 70.6% vs 78.9% (P = .78), and 88.2% vs 78.9% (P = .22). The 1-year limb salvage rate for the stent vs no-stent group was 94.1% vs 100% (P = .7). CONCLUSION: Combining subintimal angioplasty with a stent graft in femoro-popliteal lesions does not improve patency. The limb salvage rate remains high after addition of a stent graft. Rigorous monitoring is recommended to diagnose and treat restenosis early in order to improve patency.

PMID: 20692789 [PubMed - as supplied by publisher]

Endovascular procedures for aorto-iliac occlusive disease are associated with superior short-term clinical and economic outcomes compared with open surgery in the inpatient population.

J Vasc Surg. 2010 Aug 4;

Authors: Indes JE, Mandawat A, Tuggle CT, Muhs B, Sosa JA

OBJECTIVES: There has been a rapid increase in the number of endovascular procedures performed for peripheral artery disease, and especially aorto-iliac occlusive disease (AIOD). Results from single-center reports suggest a benefit for endovascular procedures; however, these benefits may not reflect general practice. We used a population-based analysis to determine predictors of clinical and economic outcomes following open and endovascular procedures for inpatients with AIOD. METHODS: All patients with AIOD who underwent open and endovascular procedures in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2004 to 2007, were identified. Independent patient- and provider-related characteristics were analyzed. Clinical outcomes included complications and mortality; economic outcomes included length of stay (LOS) and cost (2007 dollars). Outcomes were compared using chi(2), ANOVA, and multivariate regression analysis. RESULTS: Four thousand, one hundred nineteen patients with AIOD were identified. Endovascular procedures increased by 18%. Patients who underwent endovascular procedures were more likely to be >/=65 years of age (46% vs 37%), female (54% vs 49%), and in the highest quartile of household income (20% vs 16%), all P < .05. Endovascular patients were more likely to be non-elective (41% vs 20%), in the highest comorbidity index group (8% vs 5%), and with iliac artery disease (67% vs 33%), all P </= .05. In bivariate analysis, endovascular procedures were associated with lower complication rates (16% vs 25%), shorter LOS (2.2 vs 5.8 days), and lower hospital costs ($13,661 vs $17,161), all P < .001. In multivariate analysis, endovascular procedures had significantly lower complication rates and cost, and shorter LOS. CONCLUSIONS: Endovascular procedures have superior short-term clinical and economic outcomes compared with open procedures for the treatment of AIOD in the inpatient setting. Further studies are needed to examine long-term outcomes and access-related issues.

PMID: 20691560 [PubMed - as supplied by publisher]

Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR.

J Vasc Surg. 2010 Aug 4;

Authors: Beeman BR, Murtha K, Doerr K, McAfee-Bennett S, Dougherty MJ, Calligaro KD

OBJECTIVE: While the significance of type II endoleaks (T2ELs) on the long-term outcome of endovascular abdominal aneurysm repair (EVAR) to repair abdominal aortic aneurysms (AAAs) is debatable, duplex ultrasonography (DU) parameters have been suggested to be predictive of their closure or persistence. The purpose of this study was to determine which, if any, of these variables was associated with persistent T2EL or increased AAA sac diameter. METHODS: Between 1998 and 2009, 278 patients underwent EVAR and post-operative DU surveillance during long-term follow-up (1-11 years) in our accredited non-invasive vascular laboratory by one of three experienced technologists. DU measured intra-sac flow velocity (IFV), spectral doppler waveform (SDW) patterns, post-EVAR sac diameter, and number of T2ELs. RESULTS: T2ELs developed in 14% (38/278) of patients post-EVAR. Fourteen patients had T2ELs that resolved, and sac diameter decreased or remained the same: the average IFV was 42 cm/second; SDW patterns were monophasic in five, biphasic in seven and bidirectional in two; and multiple T2ELs were not present (0%) in any patient. Twelve patients had T2ELs that persisted, but sac diameter decreased or remained the same: the average IFV was 47 cm/second; SDW patterns were monophasic in one, biphasic in five, bidirectional in five, and undetermined in one; and multiple T2ELs were found in 17% (2) of patients. Twelve patients had T2ELs that persisted and were associated with increased sac diameter: the average IFV was 43 cm/second, SDW patterns were monophasic in one, biphasic in two, and bidirectional in nine; and multiple T2ELs were identified in 75% (9) of patients. None of the 38 patients with T2ELs treated with selective surgical or endovascular intervention for enlarging sac diameters (11/12) experienced a ruptured aneurysm. CONCLUSION: Contrary to previous smaller reports of T2ELs and DU surveillance, parameters such as IFV did not correlate with increased post-EVAR sac diameter. The presence of multiple T2ELs and bidirectional SDW may be the strongest factors predictive of increased sac diameter.

PMID: 20691559 [PubMed - as supplied by publisher]

Extrahepatic portal vein aneurysm.

J Vasc Surg. 2010 Aug 4;

Authors: Moreno JA, Fleming MD, Farnell MB, Gloviczki P

PMID: 20691558 [PubMed - as supplied by publisher]

Venous ulcer diagnosis, treatment, and prevention of recurrences.

J Vasc Surg. 2010 Jul 31;

Authors: Gillespie DL,

PMID: 20678885 [PubMed - as supplied by publisher]

Laparoscopic treatment of renal artery entrapment.

J Vasc Surg. 2010 Jul 31;

Authors: Bünger CM, Schareck W, Klar E, Kröger JC

Renal artery entrapment by the diaphragmatic crus is a very infrequent cause of renovascular hypertension. We present the case of a young man who was assigned to our hospital with arterial hypertension and stenosis of the left renal artery. Extrinsic compression was diagnosed by duplex ultrasound and magnetic resonance angiography. We performed laparoscopic decompression using the transperitoneal retrorenal approach. Antihypertensive medication could be stopped thereafter and duplex ultrasound revealed a normal blood flow to the left renal artery. We therefore propose laparoscopic treatment of left renal artery entrapment as a minimally-invasive alternative to open surgery.

PMID: 20678884 [PubMed - as supplied by publisher]

Preparation and characterization of injectable fibrillar type I collagen and evaluation for pseudoaneurysm treatment in a pig model.

J Vasc Surg. 2010 Jul 31;

Authors: Geutjes PJ, van der Vliet JA, Faraj KA, de Vries N, van Moerkerk HT, Wismans RG, Hendriks T, Daamen WF, van Kuppevelt TH

OBJECTIVE: Despite the efficacy of collagen in femoral artery pseudoaneurysm treatment, as reported in one patient study, its use has not yet gained wide acceptance in clinical practice. In this particular study, the collagen was not described in detail. To further investigate the potential of collagen preparations, we prepared and characterized highly purified injectable fibrillar type I collagen and evaluated its use for femoral artery pseudoaneurysm (PSA) treatment in vivo using a pig model. METHODS: Purified fibrillar type I collagen was characterized using electron microscopy. The effect of three different sterilization procedures, ie, hydrogen peroxide gas plasma (H(2)O(2)), ethylene oxide gas (EtO), and gamma irradiation, was studied on both SDS-PAGE and platelet aggregation. Different collagen injectables were prepared (3%, 4%, and 5%) and tested using an injection force test applying a 21-gauge needle. To evaluate the network characteristics of the injectable collagen, the collagen was suspended in phosphate buffered saline (PBS) at 37 degrees C and studied both macroscopically and electron microscopically. To determine whether the collagen induced hemostasis in vivo, a pig PSA model was used applying a 4% EtO sterilized collagen injectable, and evaluation by angiography and routine histology. RESULTS: Electron microscopy of the purified type I collagen revealed intact fibrils with a distinct striated pattern and a length <300 mum. Both SDS-PAGE and platelet aggregation analysis of the sterilized collagen indicated no major differences between EtO and H(2)O(2) sterilization, although gamma-irradiated collagen showed degradation products. Both 3% and 4% (w/v) collagen suspensions were acceptable with respect to the force used (<50 N). The 4% suspension was selected as the preferred injectable collagen, which formed a dense network under physiologic conditions. Testing the collagen in vivo (n = 5), the angiograms revealed that the PSA partly or completely coagulated. Histology confirmed the network formation, which was surrounded by thrombus. CONCLUSIONS: Collagen injectables were prepared and EtO sterilized without major loss of structural integrity and platelet activity. In vivo, the injectable collagen formed a dense network and triggered (partial) local hemostasis. Although optimization is needed, an injectable collagen may be used as a therapeutic agent for femoral PSA treatment.

PMID: 20678883 [PubMed - as supplied by publisher]

A clinicopathologic study of immunoglobulin G4-related sclerosing disease of the thoracic aorta.

J Vasc Surg. 2010 Jul 31;

Authors: Kasashima S, Zen Y, Kawashima A, Endo M, Matsumoto Y, Kasashima F, Ohtake H, Nakanuma Y

OBJECTIVE: Immunoglobulin G4-related sclerosing disease (IgG4-SD) has recently been reported to occur in the cardiovascular system and manifest as inflammatory abdominal aortic aneurysm. Thoracic aortic lesions are often associated with aortitis in several divergent etiologies. Thus, this study was performed to review thoracic aortic lesions from the aspect of IgG4-SD and to elucidate the clinicopathologic characteristics of this subgroup in the thoracic aorta. METHODS: The study comprised 125 patients, including 71 with thoracic aortic aneurysm (TAA), 44 with aortic dissection, 7 with Takayasu aortitis, and 3 with infectious aortitis. IgG4-SD was identified by diffuse infiltration of numerous IgG4-positive plasmacytes by immunohistochemical examinations. Clinicopathologic features were compared between IgG4-related and IgG4-unrelated lesions. RESULTS: Among the 125 patients, IgG4-SD was found in 5 patients with TAA but was not detected in the other subgroups of thoracic aortic lesion. IgG4-related TAA included one case of lymphoplasmacytic aortitis, 1 case of inflammatory aneurysm, and three cases of atherosclerotic aneurysms. Patients with IgG4-related TAA showed clinicopathologic features similar to patients with IgG4-SD: male gender, old age, history of bronchial asthma and allergies, elevation of white blood cell counts, C-reactive protein levels, and IgG4 and IgE concentrations (in one patient); eosinophilic infiltration, obliterative phlebitis, lymph follicle formation, and perineural inflammation. In addition, compared with IgG4-unrelated TAA, IgG4-related TAA was characterized by clinically more frequency of involvement of the aortic arch (P = .002), saccular formation (P = .003), and fibrous adhesion to surrounding tissue (P < .001), and histopathologically thicker entire aortic wall and adventitia (P < .001 each). CONCLUSIONS: IgG4-SD is involved in 4% of all thoracic aortic lesions and uniformly presents in the form of an aneurysm with distinct histologic and clinicopathologic features. IgG4-SD represents one, albeit rare, etiology of TAA, especially those originating in the aortic arch.

PMID: 20678882 [PubMed - as supplied by publisher]