The Pacific Vascular Symposium VI: The Venous Ulcer Summit in perspective.

J Vasc Surg. 2010 Jul 31;

Authors: Henke P,

PMID: 20678881 [PubMed - as supplied by publisher]

Hyperglycemia limits experimental aortic aneurysm progression.

J Vasc Surg. 2010 Jul 31;

Authors: Miyama N, Dua MM, Yeung JJ, Schultz GM, Asagami T, Sho E, Sho M, Dalman RL

OBJECTIVE: Diabetes mellitus (DM) is associated with reduced progression of abdominal aortic aneurysm (AAA) disease. Mechanisms responsible for this negative association remain unknown. We created AAAs in hyperglycemic mice to examine the influence of serum glucose concentration on experimental aneurysm progression. METHODS: Aortic aneurysms were induced in hyperglycemic (DM) and normoglycemic models by using intra-aortic porcine pancreatic elastase (PPE) infusion in C57BL/6 mice or by systemic infusion of angiotensin II (ANG) in apolipoprotein E-deficient (ApoE(-/-)) mice, respectively. In an additional DM cohort, insulin therapy was initiated after aneurysm induction. Aneurysmal aortic enlargement progression was monitored with serial transabdominal ultrasound measurements. At sacrifice, AAA cellularity and proteolytic activity were evaluated by immunohistochemistry and substrate zymography, respectively. Influences of serum glucose levels on macrophage migration were examined in separate models of thioglycollate-induced murine peritonitis. RESULTS: At 14 days after PPE infusion, AAA enlargement in hyperglycemic mice (serum glucose >/= 300 mg/dL) was less than that in euglycemic mice (PPE-DM: 54% +/- 19% vs PPE: 84% +/- 24%, P < .0001). PPE-DM mice also demonstrated reduced aortic mural macrophage infiltration (145 +/- 87 vs 253 +/- 119 cells/cross-sectional area, P = .0325), elastolysis (% residual elastin: 20% +/- 7% vs 12% +/- 6%, P = .0209), and neovascularization (12 +/- 8 vs 20 +/- 6 vessels/high powered field, P = .0229) compared with PPE mice. Hyperglycemia limited AAA enlargement after ANG infusion in ApoE(-/-) mice (ANG-DM: 38% +/- 12% vs ANG: 61% +/- 37% at day 28). Peritoneal macrophage production was reduced in response to thioglycollate stimulation in hyperglycemic mice, with limited augmentation noted in response to vascular endothelial growth factor administration. Insulin therapy reduced serum glucose levels and was associated with AAA enlargement rates intermediate between euglycemic and hyperglycemic mice (PPE: 1.21 +/- 0.14 mm vs PPE-DM: 1.00 +/- 0.04 mm vs PPE-DM + insulin: 1.14 +/- 0.05 mm). CONCLUSIONS: Hyperglycemia reduces progression of experimental AAA disease; lowering of serum glucose levels with insulin treatment diminishes this protective effect. Identifying mechanisms of hyperglycemic aneurysm inhibition may accelerate development of novel clinical therapies for AAA disease.

PMID: 20678880 [PubMed - as supplied by publisher]

Prevention and treatment of the postthrombotic syndrome.

J Vasc Surg. 2010 Jul 31;

Authors: Henke P,

PMID: 20678879 [PubMed - as supplied by publisher]

Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial.

J Vasc Surg. 2010 Jul 31;

Authors: Belch JJ, Dormandy J,

OBJECTIVE: Dual antiplatelet therapy with clopidogrel plus acetylsalicylic acid (ASA) is superior to ASA alone in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention. We sought to determine whether clopidogrel plus ASA conferred benefit on limb outcomes over ASA alone in patients undergoing below-knee bypass grafting. METHODS: Patients undergoing unilateral, below-knee bypass graft for atherosclerotic peripheral arterial disease (PAD) were enrolled 2 to 4 days after surgery and were randomly assigned to clopidogrel 75 mg/day plus ASA 75 to 100 mg/day or placebo plus ASA 75 to 100 mg/day for 6 to 24 months. The primary efficacy endpoint was a composite of index-graft occlusion or revascularization, above-ankle amputation of the affected limb, or death. The primary safety endpoint was severe bleeding (Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries [GUSTO] classification). RESULTS: In the overall population, the primary endpoint occurred in 149 of 425 patients in the clopidogrel group vs 151 of 426 patients in the placebo (plus ASA) group (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.78-1.23). In a prespecified subgroup analysis, the primary endpoint was significantly reduced by clopidogrel in prosthetic graft patients (HR, 0.65; 95% CI, 0.45-0.95; P = .025) but not in venous graft patients (HR, 1.25; 95% CI, 0.94-1.67, not significant [NS]). A significant statistical interaction between treatment effect and graft type was observed (P(interaction) = .008). Although total bleeds were more frequent with clopidogrel, there was no significant difference between the rates of severe bleeding in the clopidogrel and placebo (plus ASA) groups (2.1% vs 1.2%). CONCLUSION: The combination of clopidogrel plus ASA did not improve limb or systemic outcomes in the overall population of PAD patients requiring below-knee bypass grafting. Subgroup analysis suggests that clopidogrel plus ASA confers benefit in patients receiving prosthetic grafts without significantly increasing major bleeding risk.

PMID: 20678878 [PubMed - as supplied by publisher]

Therapeutic distant organ effects of regional hypothermia during mesenteric ischemia-reperfusion injury.

J Vasc Surg. 2010 Jul 31;

Authors: Santora RJ, Lie ML, Grigoryev DN, Nasir O, Moore FA, Hassoun HT

INTRODUCTION: Mesenteric ischemia-reperfusion injury (IRI) leads to systemic inflammation and multiple organ failure in clinical and laboratory settings. We investigated the lung structural, functional, and genomic response to mesenteric IRI with and without regional intraischemic hypothermia (RIH) in rodents and hypothesized that RIH would protect the lung and preferentially modulate the distant organ transcriptome under these conditions. METHODS: Sprague-Dawley rats underwent sham laparotomy or superior mesenteric artery occlusion (SMAO) for 60 minutes with or without RIH. Gut temperature was maintained at 15 degrees -20 degrees C during SMAO, and systemic normothermia (37 degrees C) was maintained throughout the study period. At 6 or 24 hours, lung tissue was collected for (1) histology, (2) myeloperoxidase activity, (3) bronchoalveolar lavage (BAL) fluid protein concentrations, (4) lung wet/dry ratios, and (5) total RNA isolation and hybridization to Illumina's Sentrix BeadChips (>22,000 probes) for gene expression profiling. Significantly affected genes (false discovery rate <5% and fold change >/=1.5) were linked to gene ontology (GO) terms using MAPPFinder, and hypothermia-suppressed genes were further analyzed with Pubmatrix. RESULTS: Mesenteric IRI-induced lung injury, as evidenced by leukocyte trafficking, alveolar hemorrhage, and increased BAL protein and wet/dry ratios, and activated a proinflammatory lung transcriptome compared with sham. In contrast, rats treated with RIH exhibited lung histology, BAL protein, and wet/dry ratios similar to sham. At 6 hours, GO analysis identified 232 hypothermia-suppressed genes related to inflammation, innate immune response, and cell adhesion, and 33 hypothermia-activated genes related to lipid and amine metabolism and defense response. Quantitative real-time polymerase chain reaction validated select array changes in top hypothermia-suppressed genes lipocalin-2 (lcn-2) and chemokine ligand 1 (CXCL-1), prominent genes associated with neutrophil activation and trafficking. CONCLUSIONS: Therapeutic hypothermia during SMAO provides distant organ protection and preferentially modulates the IRI-activated transcriptome in the rat lung. This study identifies potential novel diagnostic and therapeutic targets of mesenteric IRI and provides a platform for further mechanistic study of hypothermic protection at the cellular and subcellular level.

PMID: 20678877 [PubMed - as supplied by publisher]

The structure and processes of the Pacific Vascular Symposium VI.

J Vasc Surg. 2010 Jul 29;

Authors: Lurie F, Kistner RL, Eklof B, Wakefield T, Comerota A

This review describes development, design, and implementation of a guided process for a scientific strategic planning meeting- the Sixth Pacific Vascular Symposium. The aim of this meeting was to develop a strategic plan for a diverse field of venous diseases. This diversity extends from a variety of pathologic conditions to multiple specialties involved in care for patients with these conditions to a broad spectrum of issues affecting the progress of this field (scientific, organizational, political, economical etc). Development of this meeting included identification of a unified goal for the strategic direction, which is achievable, important, practical, and measurable. The design of the meeting was focused on addressing critical issues that need to be solved to achieve this goal. This design included parallel and colliding processes focused on scientific evidence and gaps of knowledge, and on practical initiatives that can be pursued currently. Faculty selection reflected the diversity of the field and the spectrum of necessary expertise. The structure of the meeting combined focused discussions in small group sessions and general sessions addressing key issues of the strategic plan. The result of this meeting is the plan for achieving the goal of 50% reduction of the prevalence of venous ulcers. This plan includes prioritized list of critical issues, practical steps to solve these issues, suggested timeline, and measurable landmarks of the progress. This plan serves as a call for action, and an invitation to all interested parties to address an important and neglected public health problem of venous diseases.

PMID: 20674252 [PubMed - as supplied by publisher]

A vascular disease educational program in the preclinical years of medical school increases student interest in vascular disease.

J Vasc Surg. 2010 Jul 29;

Authors: Godshall CJ, Moore PS, Fleming SH, Andrews JS, Hansen KJ, Hoyle JR, Edwards MS

BACKGROUND: New training paradigms in vascular surgery necessitate medical student interest in vascular disease. We examined the effects of incorporation of a vascular disease educational program during the second year of the medical school curriculum on student acquisition of knowledge and interest in the treatment of vascular disease. METHODS: We developed and administered a new educational program on vascular disease and delivered the program to all second-year medical students. The new program encompassed 9 didactic hours, including 7 traditional lecture hours and 2 hours of problem-based learning. After completing the program, students were surveyed regarding vascular disease-specific knowledge, interest in treating vascular disease, and career choices. Third-year students who were not exposed to the program were surveyed as a control group. We recorded the voluntary student enrollment in the vascular and endovascular surgery rotation during the following academic year. Voluntary enrollment of the students exposed to the vascular disease education program was compared with enrollment for the previous 8 years. RESULTS: Before the introduction of the new educational program, 946 total lecture hours were delivered to first- and second-year medical students, comprising 490 hours (52%) given by nonsurgeon physicians, 445 (47%) by nonphysicians, and 11 (1%) by surgeons. Survey response rate was 93% (112 of 121) for second-year students and 95% (39 of 41) for third-year students. After the vascular disease program, second-year students answered 7.1 +/- 1.4 of 9 vascular disease questions correctly, whereas unexposed third-year students answered 7.2 +/- 1.7 questions correctly (P = .96). Most second-year medical students described a "somewhat" or "much greater" interest in the medical (63%), procedural (59%), and overall (63%) management of vascular disease after exposure to the program. Most also had a "somewhat" or "much greater" interest in a vascular medicine (64%) or vascular and endovascular surgery (60%) rotation. Enrollment in the vascular surgery third-year clerkship increased significantly to a mean of 3.0 students/month from 1.16 students/month in the prior year (P = .0032, postintervention year vs 8 prior years). CONCLUSION: A vascular disease educational program administered to second-year medical students increases interest in vascular disease and interest in further training. The increased interest translates to greater student enrollment in the vascular surgery clerkship in the subsequent academic year.

PMID: 20674251 [PubMed - as supplied by publisher]

Discussion.

J Vasc Surg. 2010 Jul 29;

Authors:

PMID: 20674250 [PubMed - as supplied by publisher]

Seventeen-year follow-up after ascending-to-infrarenal aorta bypass for recurrent coarctation in an adult.

J Vasc Surg. 2010 Jul 29;

Authors: Pereda D, Cartañá R, Sundt TM, Mestres CA

Anatomic repair of complex aortic coarctation is associated with significant mortality and morbidity, including paraplegia. Extra-anatomic bypass strategies have been developed to reduce these complications and allow the correction of any concomitant conditions during the same operation. We present the case of a woman with uncontrolled hypertension and preductal coarctation of the aorta diagnosed at age 22 who underwent an unsuccessful attempt at primary repair, followed by extra-anatomic bypass from the ascending-to-infrarenal aorta. The patient has remained normotensive, with no additional complications related to the disease or the procedure, during a follow-up of 17 years.

PMID: 20674249 [PubMed - as supplied by publisher]

Prior endovascular abdominal aortic aneurysm repair provides no survival benefits when the aneurysm ruptures.

J Vasc Surg. 2010 Jul 29;

Authors: Cho JS, Park T, Kim JY, Chaer RA, Rhee RY, Makaroun MS

OBJECTIVE: It has been proposed that prior endovascular abdominal aortic aneurysm (AAA) repair (EVAR) confers protective effects in the setting of ruptured AAA (rAAA). This study was conducted to compare outcomes of rAAA repairs in patients with and without prior EVAR. METHODS: A retrospective review identified 18 patients with (group 1) and 233 patients without (group 2) antecedent EVAR who presented with rAAA from January 2001 to December 2008. Patient characteristics and perioperative variables were noted and the outcomes were compared. Multiple logistic regression was used to identify factors contributing to morbidity and mortality and Kaplan-Meier analyses to estimate late survival rates. RESULTS: Baseline characteristics were similar between groups. Mean age was 78 years in group 1 and 74.8 years in group 2 (P = .17). Men comprised 83.3% of patients in group 1 and 77.3% in group 2 (P = .77). Hemodynamic instability at rAAA was noted with similar frequency between groups, 55.6% vs 52.6%, respectively (P = .99). Mean time from EVAR to rAAA was 4.0 years and from last follow-up computed tomography (CT) 1.2 years. The devices involved were Ancure (Guidant, Menlo Park, Calif) (9), AneuRx (Medtronic, Minneapolis, Minn) (5), Zenith (Cook Medical Inc, Bloomington, Ind) (3), and Excluder (W.L Gore, Flagstaff, Ariz) (1). Mean preoperative AAA size was 6.4 cm in group 1. All but 1 patient had an endoleak at the time of rupture. Of 14 patients with CT follow-up, only 3 patients had a known increase in size (>/=5 mm) and only 3 were known to have an endoleak. Fifteen patients were treated by a single intervention, whereas 3 patients underwent multiple procedures. In group 2, open repair was performed in 218 patients and EVAR in 15. Morbidity (66.7% vs 56.7%) and in-hospital mortality (38.9% vs 36.9%) were nearly identical between groups. One-year survival rates (27.8% vs 48.2%; P = .15) were also similar. The mortality rates for EVAR for primary rAAA was 20% as compared to 38.1% for open repair for rAAAs (P = .27). CONCLUSION: rAAA remains a lethal problem in patients with and without prior EVAR alike. An existing endograft provides neither acute nor 1-year survival benefits after rAAA repairs. Prediction of patients at risk for rupture post-EVAR is difficult, as only a minority of patients had a known prior endoleak or sac enlargement.

PMID: 20674248 [PubMed - as supplied by publisher]

Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease.

J Vasc Surg. 2010 Jul 29;

Authors: Vouyouka AG, Egorova NN, Salloum A, Kleinman L, Marin M, Faries PL, Moscowitz A

INTRODUCTION: Despite overall improvement, there is still a gender-related disparity in the outcomes of lower extremities peripheral arterial disease (PAD). We analyzed sex-related variability among factors that are known to influence outcomes. METHODS: Data on PAD inpatient hospitalizations from New York, New Jersey, and Florida state hospital discharge databases (1998-2007) were analyzed using univariate and multivariate logistic regression analyses. RESULTS: Of the 372,692 surgical hospitalizations identified, 162,730 (43.66%) involved women. Men and women undergoing vascular procedures differed in that more men smoked (18% vs 14%, P < .0001), and more men had coronary artery disease (40% vs 33%, P < .0001). Women were more likely to be obese (11.86% vs 4.89%; P <.0001), black (18.81% vs 12.66%; P < .0001), older, and have critical limb ischemia (CLI) (39.41% vs 37.67%; P < .0001). They had higher mortality (5.26% vs 4.21%; P < .0001) and complication rates, especially bleeding (10.62 % vs 8.19%; P < .0001) and infection (3.23% vs 2.88%; P < .0001). Mortality rates after endovascular procedures were lower and showed marginal difference between genders (2.87% vs 2.11%; P < .0001). The difference was more pronounced after open revascularizations (5.05% for women vs 4.00% for men; P <.0001) and amputations (9.82% for women vs 8.82% for men; P < .0001). Bleeding differences between men and women were greatest when both open and endovascular procedures were done during the same hospitalizations and lowest after major amputations. Similar to bleeding, transgender differences in postoperative infections were more pronounced after combination of open and endovascular procedures. Using a multivariable model, female gender remained a predictor of perioperative mortality, infection, and bleeding after vascular intervention (odds ratios 1.15, 1.21, and 1.32, respectively). Female gender negatively influenced the mortality of patients with cerebrovascular and coronary disease and those of black race even after adjusting for relevant clinical and demographic risk factors. Gender effect on mortality dissipated in octogenarians and patients with claudication. CONCLUSION: Female gender continues to be an important risk factor that negatively influences the outcomes of vascular interventions; however, these effects vary between different high-risk groups and procedures. Gender effect on mortality dissipates in elderly patients. Prompt recognition of the associations between gender and various risk factors of cardiovascular disease and aggressive modification of these risk factors in female patients may improve gender-related disparity in the outcomes of vascular disease.

PMID: 20674247 [PubMed - as supplied by publisher]

Usefulness and limitations of computational models in aortic disease risk stratification.

J Vasc Surg. 2010 Jul 29;

Authors: Beller CJ, Gebhard MM, Karck M, Labrosse MR

OBJECTIVE: In risk stratification of aortic diseases such as aneurysm and aortic dissection, diameter is one parameter whose influence on the average aortic wall stress is directly described by the Laplace law. More advanced mechanical models can be used and may yield additional information, such as transmural stress distributions. The question then arises of how refined models need to be to provide clinicians with practical help. METHODS: Two sets of finite element models were used. The relative roles of diameter, material stiffness, longitudinal stretch, blood pressure, wall thickness, and vessel curvature were explored using simplified aortic models for comparison with the Laplace law. The influences of the material properties nonlinearity and residual stress on the transmural stress distribution were investigated using an advanced aortic model including recent experimental findings in older humans. RESULTS: The Laplace law was confirmed as one effective, basic tool to assess the average wall stress in the aortic wall, both in the circumferential and longitudinal directions. However, the simplified models were sufficient to show that, as already reported in the literature, longitudinal stretch and vessel curvature have potentially equally strong or even stronger contributions to wall stress than the parameters included in the Laplace law. When the advanced model was used, and residual stress induced by large opening angles such as found in older subjects was introduced, the transmural stress gradient was found inverted compared with expectations, with the largest stresses now toward the adventitia. The results suggested that the intima may be increasingly shielded from higher stresses as one gets older, which might be protective against the initiation of dissection tears in the thoracic aorta. CONCLUSION: Biomechanical analysis of the aorta may be refined by using increasingly detailed computational models. Simplified models can readily improve on the Laplace law in the assessment of aortic wall stress, and as such, may already contribute to better risk stratification of aortic disease. Advanced models may also enhance our understanding of the mechanistic aspects in the pathogenesis of aortic disease. However, their applicability in a patient-specific context may be limited by the large number of input data they require, some of which might stay out of the clinicians' reach.

PMID: 20674246 [PubMed - as supplied by publisher]

Midterm outcome of endovascular repair of ruptured isolated iliac artery aneurysms.

J Vasc Surg. 2010 Jul 29;

Authors: Hechelhammer L, Rancic Z, Pfiffner R, Mayer D, Meier T, Lachat M, Pfammatter T

PURPOSE: This study analyzed the clinical and morphologic outcomes of endovascular treatment of ruptured isolated iliac artery aneurysms (RIIAA) at midterm follow-up. METHODS: Eleven patients with RIIAA (1 woman, 10 men; mean age, 73 years; mean IIAA diameter, 69.1 mm) were identified in a single-center database of patients who underwent endovascular aortoiliac aneurysm repair between April 2001 and December 2009. Devices inserted included 9 leg endografts in 7 patients (Excluder, n = 7; Zenith, n = 2), 3 bifurcated stent grafts in 3 patients (Excluder), and 1 aortouniiliac stent graft in 1 patient (Zenith). Endovascular occlusion of the internal iliac artery or its branches was performed in all cases by coils (n = 10) or Amplatzer occluder plug (n = 1). Immediately after endovascular aneurysm exclusion, a computed tomography (CT) angiography was obtained in nine patients. Except for this adjunct postimplantation CT scanning, the imaging follow-up was the same as for nonruptured aortoiliac aneurysms at 3, 6, and 12 months and annually thereafter. RESULTS: Mean delay from hospital admission to intervention was 78.5 minutes. Mean intervention time was 150 minutes. The assisted primary technical success rate was 100%. Median lengths of stay were 2 days in the intensive care unit and 13 days in the hospital. Abdominal compartment syndrome developed in three patients who received open abdomen treatment. The 30-day mortality was 18%. The mean follow-up was 23 months (range, 0-69 months). There were no late deaths during the follow-up. There was no need for late surgical conversion. Aneurysm sac shrinkage (defined as >5 mm) was recorded in five patients, whereas the sac diameter remained stable in four. There was no patient with aneurysm sac growth. Additional stent graft insertion as the only secondary intervention for a type Ib leak was performed. Type II endoleaks (primary and secondary) were found in 36% and secondary Ib in 9% of the patients. CONCLUSION: Emergency stent grafting of RIIAA is feasible and safe with good midterm outcome.

PMID: 20674245 [PubMed - as supplied by publisher]

Microcirculatory effects of local and remote ischemic preconditioning in supraceliac aortic clamping.

J Vasc Surg. 2010 Jul 29;

Authors: Erling N, Nakagawa NK, Cruz JW, Zanoni FL, Baptista-Silva JC, Sannomiya P, Poli-de-Figueiredo LF

INTRODUCTION: Supraceliac aortic clamping in major vascular procedures promotes splanchnic ischemia and reperfusion (I/R) injury that may induce endothelial dysfunction, widespread inflammation, multiorgan dysfunction, and death. We tested the hypothesis that local or remote ischemic preconditioning (IPC) may be protective against injury after supraceliac aortic clamping through the modulation of mesenteric leukocyte-endothelial interactions, as evaluated with intravital microscopy and expression of adhesion molecules. METHODS: Fifty-six male Wistar rats (weight, 190 to 250 g), were divided into four groups of 14 rats each: control-sham surgery without aortic occlusion; I/R through supraceliac aortic occlusion for 20 minutes, followed by 120 minutes of reperfusion; local IPC through supraceliac aortic occlusion for two cycles of 5 minutes of ischemia and 5 minutes of reperfusion, followed by the same protocol of the IR group; remote IPC through infrarenal aortic occlusion for two cycles of 10 minutes of ischemia and 10 minutes of reperfusion, followed by the same protocol of IR group. Seven animals per group were used to evaluate in vivo leukocyte-endothelial interactions in postcapillary venules with intravital microscopy and another seven animals per group were used to collect mesentery samples for immunohistochemistry demonstration of adhesion molecules expression. RESULTS: Supraceliac aortic occlusion increased the number of rolling leukocytes with slower velocities and increased the number of adherent leukocytes to the venular surface and leukocyte migration to the interstitium. The expression of P-selectin, E-selectin, and intercellular adhesion molecule-1 were also increased significantly after I/R. Local or remote IPC reduced the leukocyte recruitment in vivo and normalized the expression of adhesion molecules. CONCLUSIONS: Local or remote IPC reduces endothelial dysfunction on mesenteric microcirculation caused by I/R injury after supraceliac aortic clamping.

PMID: 20674244 [PubMed - as supplied by publisher]

Incorporating simulation in vascular surgery education.

J Vasc Surg. 2010 Jul 29;

Authors: Bismuth J, Donovan MA, O'Malley MK, El Sayed HF, Naoum JJ, Peden EK, Davies MG, Lumsden AB

The traditional apprenticeship model introduced by Halsted of "learning by doing" may just not be valid in the modern practice of vascular surgery. The model is often criticized for being somewhat unstructured because a resident's experience is based on what comes through the "door." In an attempt to promote uniformity of training, multiple national organizations are currently delineating standard curricula for each trainee to govern the knowledge and cases required in a vascular residency. However, the outcomes are anything but uniform. This means that we graduate vascular specialists with a surprisingly wide spectrum of abilities. Use of simulation may benefit trainees in attaining a level of technical expertise that will benefit themselves and their patients. Furthermore, there is likely a need to establish a simulation-based certification process for graduating trainees to further ascertain minimum technical abilities.

PMID: 20674243 [PubMed - as supplied by publisher]

Warfarin anticoagulation before angioplasty relieves thrombus burden in Budd-Chiari syndrome caused by inferior vena cava anatomic obstruction.

J Vasc Surg. 2010 Jul 29;

Authors: Li T, Zhang WW, Bai W, Zhai S, Pang Z

OBJECTIVES: Pulmonary embolism (PE) is one of the major complications after percutaneous balloon angioplasty (PTBA) for Budd-Chiari's syndrome (BCS). The purpose of this study was to investigate the role of warfarin pre-treatment in the prevention of PE after PTBA in patients with large inferior vena cava (IVC) thrombus. PATIENTS AND METHODS: From October 2002 to December 2009, 16 patients with symptomatic membranous or segmental IVC occlusion and large thrombus were treated with warfarin before PTBA. Eleven patients were men and 5 were women. The median age was 36 years, ranging from 21 to 52 years. The median duration of warfarin treatment before PTBA was 7 months, ranging from 3 to 12 months. Fourteen patients had membranous IVC occlusion and 2 had segmental occlusion. All 16 patients had significant thrombi underneath the obstructive lesions. PE diagnosis was based on clinical presentation and pulmonary computerized tomographic angiogram, if indicated. RESULTS: In 14 of 16 patients, IVC thrombus was completely or near-completely resolved based on follow-up cavogram and PTBA was performed. In the other 2 patients, residual thrombus was demonstrated by cavogram at 12 months. PTBA and stent placement were carried out. IVC patency in the 16 patients was confirmed by completion cavogram. No major bleeding complication during warfarin pre-treatment aimed to keep international normalized ratio (INR) 2 to 3. There was no clinically significant PE or death in this group during follow-up, ranging from 6 to 40 months (median 21 months). CONCLUSION: Spontaneous fibrinolysis of IVC thrombus occurs within 1 year in the majority of the patients treated with warfarin. Pre-treatment with warfarin prevents PE after PTBA in the patients with BCS with IVC membranous or segmental occlusion and large thrombus.

PMID: 20674242 [PubMed - as supplied by publisher]

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Discussion.

J Vasc Surg. 2010 Jul 22;

Authors:

PMID: 20655693 [PubMed - as supplied by publisher]

Urgent interventional bilateral renal artery fenestration for giant pararenal abdominal aortic aneurysm with upper digestive tract obstruction.

J Vasc Surg. 2010 Jul 22;

Authors: Ouyang C, Liang H

OBJECTIVE: During the past 20 years, open repair has been the chief intervention for pararenal abdominal aortic aneurysm (AAA). Endovascular repair has become an alternative for patients with ruptured AAA or other acute disease complications. The present study, however, attempted to use a common stent graft with the fenestration technique, rather than a customized one, in an emergency situation, to treat a giant pararenal AAA complicated by upper digestive tract obstruction, and assessed the results. METHODS: A patient with a pararenal AAA was admitted emergently, with complications of upper digestive tract obstruction, including a tumor-like dilated segment of the abdominal aorta, 0.5-cm inferior to the ostia of the bilateral renal arteries, with a maximum diameter of 10.1 cm and a length of 18.5 cm. The patient underwent endovascular repair with a fenestrated endovascular stent graft to open the bilateral renal arteries 1 week later in an emergency situation. RESULTS: No stenosis occurred at the openings of bilateral renal artery as a result of the stent, and the AAA was completely occluded. The patient experienced greatly ameliorated abdominal pain and upper digestive tract obstruction. At the 1-year follow-up examination, no exceptional symptoms were observed. CONCLUSION: These results showed that for patients with a pararenal AAA who are unfit for open repair, or for those who cannot wait longer than 6 weeks for a customized fenestrated stent graft to be made, emergency field fenestration is feasible and successful, based on selection of the proper patient and accurate intraoperative localization.

PMID: 20655692 [PubMed - as supplied by publisher]

Period frequency of iliofemoral venous occlusive disease by Doppler ultrasound and corresponding treatment in a tertiary care facility.

J Vasc Surg. 2010 Jul 22;

Authors: Crisostomo PR, Cho J, Feliciano B, Klein J, Jones D, Dalsing MC

BACKGROUND: Patients with iliofemoral deep venous thrombosis (DVT) are at highest risk for the postthrombotic morbidity including all aspects of the postthrombotic syndrome. Invasive therapies such as catheter-directed thrombolysis (CDT) and/or mechanical thrombectomy with or without angioplasty and stenting and in some cases open operative thrombectomy improves venous patency, venous valve function, and quality of life in patients with acute iliofemoral DVT. What is the current frequency of acute iliofemoral DVT and how aggressively is it being treated? We hypothesize that the 10-year period frequency of iliofemoral DVT among acute DVT cases is greater than previously reported. Further, we hypothesize that thrombus removal to treat acute iliofemoral DVT is little utilized in current practice. METHODS: Indiana University (IU) vascular laboratory records from January 1, 1998 to December 31, 2008 were searched by CPT code for venous Doppler ultrasound study (n = 7240). A random sample based on the IU medical record number of lower extremity Doppler studies was then selected (n = 1020) for retrospective chart review. Corresponding clinical information was gathered from the patients' electronic medical record. RESULTS: Acute DVT occurred in 6.8%, and chronic DVT in 8.8% of patients studied (25.7% inpatient, 61.7% female; median age, 56.0 years [range, 4-91 years, 1.1% less than 16 years]). History of previous DVT (33.3%) and cancer (30.4%) were the most common risk factors in patients with acute DVT. Iliofemoral DVT defined as having an iliac or common femoral vein component was identified in 49.3% of acute DVT and in 36.0% of chronic DVT. CDT was utilized in 14.3% and mechanical thrombectomy in 4.8% of acute iliofemoral DVT, and was never used with distal DVT. Warfarin anticoagulation + unfractionated heparin or low-molecular-weight heparin overlap was the most common treatment for acute iliofemoral DVT (100.0%). In 2008, the referral base of our laboratory increased significantly. Acute DVT occurred significantly less often during the 1-year period 2008 (5.3%) than the 10-year period 1998-2007 (7.6%), but iliofemoral + common femoral DVT as a component of acute DVT did not differ significantly. CONCLUSIONS: Iliofemoral DVT may be more frequent than previously reported and represents a significant portion of acute DVT. Current recommendations of acute thrombus removal for the treatment of iliofemoral DVT is underutilized suggesting that perhaps greater education of clinicians and patients regarding invasive therapy for iliofemoral DVT is required.

PMID: 20655691 [PubMed - as supplied by publisher]