Objectives: Endovascular aneurysm repair (EVAR) in hostile neck has been associated with adverse ... more Objectives: Endovascular aneurysm repair (EVAR) in hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and post-operative outcomes. Methods: This was a retrospective review of intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (> 60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated the optimal cutoff value of the aortic neck angle-length index. Patients were classified into two groups using latent profile analysis. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared. Results: 115 patients were included. Group 1(G1), aortic neck angle-length index ≤ 4.8, had 95 patients and Group 2 (G2), aortic neck ang...
l l Purpose: To ascertain if a percutaneously delivered venous valve bioprosthesis (PVVB) can be ... more l l Purpose: To ascertain if a percutaneously delivered venous valve bioprosthesis (PVVB) can be implanted in the porcine venous system and function without complications. Methods: The PVVB is a glutaraldehyde-preserved, valve-bearing venous xenograft su-tured inside a memory-coded nitinol frame (diameter 10, 12, or 14 mm). In 10 50-kg pigs, the external jugular vein was exposed, and a 16-F introducer sheath was positioned in the common iliac vein. One PVVB was inserted and deployed in each iliac vein under ¯uoro-scopic control. After PVVB implantation, all animals were randomly given either vitamin K antagonists (1±2 mg/d) (group I) or a combination of aspirin (150 mg/d) and clopidogrel (75 mg/d) (group II), which were shown in a preliminary pilot study to be the most effective anticoagulation regimens in the pig model. Ascending and descending completion phle-bograms were performed. PVVBs were evaluated with phlebography at 4 weeks to assess patency and competence; all PVVBs were ...
The benefit of catheter-directed thrombolysis for peripheral arterial occlusions is limited by he... more The benefit of catheter-directed thrombolysis for peripheral arterial occlusions is limited by hemorrhagic complications. Plasma fibrinogen level (PFL) has been suggested as a predictor of these hemorrhagic complications, but the accurateness of prediction is unknown. We summarized the available evidence on the predictive value of PFL for hemorrhagic complications after catheter-directed thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions. We systematically searched PubMed and Embase until January 2016 for peer-reviewed publications on adults undergoing thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions, assessing the predictive value of PFL for hemorrhagic complications. Two authors independently performed data extraction. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. In total, six studies (two randomized clinical trials and four cohort studies) reported on 613 patients unde...
Unplanned hospital readmissions following surgical interventions are associated with adverse even... more Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions. We identified all patients undergoing an infrainguinal endovascular intervention in the targeted vascular module of the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2014. Perioperative outcomes were stratified by symptom status (chronic limb-threatening ischemia [CLI] vs claudication). Patients who died during index admission and those who remained in the hospital after 30 days were excluded. Indications for unplanned readmission related to the index procedure were evaluated. Multivariable logistic regressio...
Patients on P2Y12 inhibitors may still develop thrombosis or bleeding complications. Tailored ant... more Patients on P2Y12 inhibitors may still develop thrombosis or bleeding complications. Tailored antiplatelet therapy, based on platelet reactivity testing, might reduce these complications. Several tests have been used, but failed to show a benefit of tailored antiplatelet therapy. This could be due to the narrowness of current platelet reactivity tests, which are limited to analysis of platelet aggregation after stimulation of the adenosine diphosphate (ADP)-pathway. However, the response to ADP does not necessarily reflect the effect of P2Y12 inhibition on platelet function in vivo. Therefore, we investigated whether measuring platelet reactivity toward other physiologically relevant agonists could provide more insight in the efficacy of P2Y12 inhibitors. The effect of in vitro and in vivo P2Y12 inhibition on αIIbβ3-activation, P-selectin and CD63-expression, aggregate formation, release of alpha, and dense granules content was assessed after stimulation of different platelet activa...
Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices... more Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices have been associated with acute hypertension, elevated pulse pressure, cardiac remodelling and reduced coronary perfusion. However, a systematic assessment of such cardiovascular effects of thoracic endovascular aortic repair (TEVAR) is missing. The CardiOvascular Remodelling following Endovascular aortic repair (CORE) study aims to (1) quantify cardiovascular remodelling following TEVAR and compare echocardiography against MRI, the reference method; (2) validate computational modelling of cardiovascular haemodynamics following TEVAR using clinical measurements, and virtually assess the impact of more compliant stent grafts on cardiovascular haemodynamics; and (3) investigate diagnostic accuracy of ECG and serum biomarkers for cardiac remodelling compared to MRI. This is a prospective, nonrandomised, observational cohort study. We will use MRI, CT, echocardiography, intraluminal pressur...
Background and aims: Peripheral arterial disease (PAD) is a common manifestation of atheroscleros... more Background and aims: Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis with an increasing incidence worldwide. The disease is still associated with high morbidity and mortality risks. Previous research in carotid arteries indicates that atherosclerotic plaque characteristics have stabilized over time in patients considered for surgery. It is currently unknown whether this timedependent stabilization occurs in ilio-femoral arteries as well. Our objective was to analyze whether local ilio-femoral atherosclerotic plaque characteristics have changed over time. Methods: 497 patients within the Athero-Express biobank who underwent primary endarterectomy of the iliac or femoral artery between 2002 and 2013 were analyzed. We investigated six histological plaque characteristics: calcification, collagen, fat content, intraplaque haemorrhage, macrophages and smooth muscle cells. Results: Over the course of 10 years, we observed a lower percentage of all plaque characteristics that are considered indicators of a vulnerable plaque, such as: plaques with a large lipid core from 37.9% to 14.9% and plaques with intraplaque haemorrhage from 69.0% to 34.8% when the two-year cohorts 2003e2004 and 2011e2012 were compared, respectively. Multivariable analyses showed that time-dependent changes occurred independently of changing procedural and patient characteristics. Conclusions: In this cohort of peripheral arterial disease patients undergoing primary endarterectomy, we observed a time dependent shift of plaque characteristics towards a less lipid rich lesion with less intraplaque haemorrhage. These findings indicate research in cardiovascular disease would benefit from contemporary patient characteristics and plaque specimens to optimize translational potential.
In patients with acute coronary syndrome, high platelet reactivity (PR) is associated with an inc... more In patients with acute coronary syndrome, high platelet reactivity (PR) is associated with an increased risk of secondary thrombotic events. However, in patients undergoing elective percutaneous coronary intervention (PCI), no association between high PR and outcome has been demonstrated. At present, the relation of PR and clinical symptoms is unknown. To examine the association of PR with clinical indication for diagnostic angiography (stable or unstable coronary artery disease [CAD]), taking into account the influence of P2Y 12 inhibitors. A platelet function score (PFS) was determined in 195 patients by quantifying fibrinogen binding and P-selectin expression with flow cytometry. We evaluated the PFS with clinical presentation of stable or unstable CAD, angiographic severity of CAD, and the incidence of cardiovascular events during 2 years of follow-up. All data were analyzed stratified by P2Y 12 inhibitor use (long-term and preprocedural versus none). Surprisingly, among non-P2Y 12 inhibitor users, the PFS was lower in patients with unstable CAD compared with stable CAD (5.6 AE 1.8 vs. 7.4 AE 1.6; p ¼ 0.001). Angiographic CAD severity showed no relation with PFS. The SYNTAX score tended to be inversely related with PFS: low PFS, 13.2 (IQR, 11.9-19.1); median PFS, 10.0 (IQR, 5.0-14.0); and high PFS, 8.0 (IQR, 5.0-13.0), without significance (p ¼ 0.304). Patients with low PFSs required more re-PCIs than those with median and high PFSs (11.1 vs. 4.7 vs. 0.0%, p ¼ 0.004). This association was modified for patients using P2Y 12 inhibitors. Among patients without P2Y 12 inhibitors undergoing coronary angiography, presentation of unstable CAD is independently associated with lower PR.
Diabetes mellitus (DM) is associated with peripheral arterial disease (PAD) and leads to worse cl... more Diabetes mellitus (DM) is associated with peripheral arterial disease (PAD) and leads to worse clinical outcome compared with patients without DM. The objective of this study was to determine the impact of DM on iliofemoral artery plaque characteristics and to examine secondary clinical outcomes in patients with DM and PAD undergoing surgical revascularization. We analyzed 198 patients with and 453 patients without DM from the Athero-Express biobank, a prospective ongoing biobank study, who underwent endarterectomy of the femoral or iliac artery between 2002 and 2013. Seven histologic plaque characteristics (calcification, collagen, lipid core, intraplaque hemorrhage, macrophages, microvessels, and smooth muscle cells) and secondary clinical outcome were compared. Composite outcome consisted of any of the following secondary manifestations of cardiovascular disease: stroke, myocardial infarction, cardiovascular death, or peripheral intervention. In addition, target vessel revascular...
This study evaluated the concept of percutaneous closure of insufficient veins using the VeinScre... more This study evaluated the concept of percutaneous closure of insufficient veins using the VeinScrew principle. The VeinScrew is designed to place a spring-shaped implant that contracts and clamps around the vein. The ability of the device to occlude adequately was tested in a bench model experiment. The feasibility of accurate placement and adequate venous occlusion was evaluated in an animal experiment and in a human cadaveric experiment. The VeinScrew implant occluded up to a pressure of 135 mmHg. In vivo studies confirmed that deployment was challenging but technically feasible, and subsequent phlebography showed closure of the vein. The cadaveric study showed that percutaneous placement of the evolved VeinScrew around the great saphenous vein was feasible and accurate. The current studies show the feasibility of the VeinScrew concept. Future developments and translational studies are necessary to determine the potential of this technique as a new option in the phlebologist's ...
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, Jan 8, 2016
To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic ... more To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic repairs using mobile, fixed, or fixed C-arms with 3-dimensional image fusion (3D-IF). A systematic search was performed to identify original articles reporting fluoroscopy time (FT) and the kerma area product (KAP) during endovascular aortic repairs. Data were grouped by noncomplex or complex (fenestrated, branched, or chimney) repairs and stratified by type of C-arm. The search identified 27 articles containing 51 study groups (35 noncomplex and 16 complex) that included 3444 patients. Random-effects meta-analysis and meta-regression models were used to calculate the pooled mean estimates of KAP and FT, as well as any effect of equipment or type of intervention. Results are presented with the 95% confidence interval and the statistical heterogeneity (I(2)). Within the noncomplex procedure studies, a significant (p<0.001) increase was found in the pooled mean KAP estimate in the fixed...
Background: Endovascular treatment of peripheral arterial disease (PAD) still yields unsatisfacto... more Background: Endovascular treatment of peripheral arterial disease (PAD) still yields unsatisfactory patency rates. Recent new developments include the use of bioresorbable stents. The objective of this study was to provide an overview of currently available data on the use of bioresorbable stents in lower limb PAD and to summarize the needs for future research focus. Methods: A systematic search in the databases of MEDLINE, Embase, and the Cochrane Library was performed. Studies using predefined inclusion and exclusion criteria were included and critically appraised by two independent reviewers. Inclusion criteria were (1) original data on (2) bioresorbable stents in (3) lower limb arteries including the iliac tract. Primary end points were safety and feasibility of bioresorbable stents, including 30-day adverse events. Secondary end points included radial force, bioresorption process, long-term primary and secondary patency, and clinical outcomes, such as amputation rate, Rutherford category, and ankle-brachial index improvement. Results: Seven published studies with a total of 316 patients were included, and five conference abstracts including 272 patients were assessed. Median follow-up time was 12 months. Overall technical success rate was 99% (range, 95.0%-100%). The 30-day adverse event rates were reported in 5.0% of patients (range, 0%-13.3%); these included one death, two major amputations, and seven reinterventions. Mean primary patency rate was 61.6% in the femoral arteries (range, 32.1%-80.0%) after 6 to 12 months compared with 50.3% in below-the-knee lesions (range, 31.8%-92.9%). Secondary patency rates were 91.5% (range, 84%-97.1%) and 72.1% (range, 62.9%-100%), respectively. The 1-year amputation rate was 3.0% in the whole group (range, 0%-12.4%). Conclusions: Experience with the use of bioresorbable stents in PAD is still limited and is investigated only in small studies. The use of bioresorbable stents in PAD appears to be feasible and safe. With current published results, we are unable to fully answer all of the questions about the future use of bioresorbable stents in PAD, and use should be limited to study-related cases in PAD.
The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q f... more The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007-2010 in the Netherlands. In November 2009, an ongoing screening program for Q fever was initiated. Patients with abdominal aortic and/or iliac disease were screened for presence of IgM and IgG antibodies to phase I and II antigens of Coxiella burnetii using immunofluorescence assay and presence of C. burnetii DNA in sera and/or vascular wall tissue using polymerase chain reaction (PCR). A total of 770 patients with abdominal aortic and/or iliac disease were screened. Antibodies against C. burnetii were detected in 130 patients (16.9%), of which 40 (30.8%) patients showed a serological profile of chronic Q fever. Three patients presented with acute Q fever, one of which developed to chronic Q fever over time. The number of aneurysm-related acute complications in patients with chronic Q fever was significantly higher compared to patients negative for Q fever (p = 0.013); 9.0% (30/333) vs. 30.0% (6/20). Eight out of 46 patients with past resolved Q fever (8/46, 17.4%) presented with aneurysm-related acute complications (no significant difference). The prevalence of chronic Q fever in C. burnetii seropositive patients with abdominal aortic and/or iliac disease living in an epidemic area in the Netherlands is remarkably high (30.8%). Patients with an aneurysm and chronic Q fever present more often with an aneurysm-related acute complication compared to patients without evidence of Q fever infection.
Diabetes is a risk factor for atherosclerotic disease but negatively associated with the developm... more Diabetes is a risk factor for atherosclerotic disease but negatively associated with the development and progression of abdominal aortic aneurysm (AAA). Advanced glycation end products (AGEs) are increased in diabetes and renders the vascular matrix more resistant to proteolysis. We assessed the concentration of AGEs in AAA biopsies obtained from diabetic and nondiabetic patients and hypothesized that (nonenzymatic) glycation of AAA tissue protects against proteolytic breakdown of collagen. AAA biopsies were collected from 30 diabetic and 30 matched nondiabetic AAA patients at the time of open repair. Aortic control samples from 10 nondiabetic and 16 diabetic patients were collected, and concentrations of the AGE cross-link pentosidine was measured. Furthermore, noncross-linking AGEs (adducts), as well as proteolytic enzymes known to play a role in aneurysm development (matrix metalloproteinase [MMP]-2, MMP-9, cathepsin B and S) were quantified. Ex vivo, nondiabetic AAA biopsies wer...
Traditional carotid endarterectomy is considered to be the standard technique for prevention of a... more Traditional carotid endarterectomy is considered to be the standard technique for prevention of a new stroke in patients with a symptomatic carotid stenosis. Use of plexus anesthesia or general anesthesia in traditional carotid endarterectomy is, to date, not unequivocally proven to be superior to one other. A systematic review was needed for evaluation of benefits and harms to determine which technique, plexus anesthesia or general anesthesia is more effective for traditional carotid endarterectomy in patients with symptomatic carotid stenosis. Methods: The review was conducted according to our protocol following the recommendations of Cochrane and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were updated on the October 1, 2020. We did not find any randomized clinical trial comparing plexus anesthesia and general anesthesia in carotid endarterectomy with patch angioplasty matching our protocol criteria in patients with a symptomatic and significant (≥50%) carotid stenosis. Conclusions: Based on the current, high risk of bias evidence, we concluded there is a need for new randomized clinical trials with overall low risk of bias comparing plexus anesthesia with general anesthesia in carotid endarterectomy with patch closure of the arterial wall in patients with a symptomatic and significant (≥50%) stenosis of the internal carotid artery. Protocol unique identification number (UIN): CRD42019139913, (https://www.crd.york.ac.uk/prospero/displa y_record.php?RecordID=139913);
This study addresses the use of decision analysis and Markov models to make contemplated decision... more This study addresses the use of decision analysis and Markov models to make contemplated decisions for surgical problems. Decision analysis and decision modeling in surgical research are increasing, but many surgeons are unfamiliar with the techniques and are skeptical of the results. The goal of this review is to familiarize surgeons with techniques and terminology used in decision analytic papers, to provide the reader a practical guide to read these papers, and to ensure that surgeons can critically appraise the quality of published clinical decision models and draw well founded conclusions from such reports.First, a brief explanation of decision analysis and Markov models is presented in simple steps, followed by an overview of the components of a decision and Markov model. Subsequently, commonly used terms and definitions are described and explained, including quality-adjusted life-years, disability-adjusted life-years, discounting, half-cycle correction, cycle length, probabil...
aneurysm-related risk after open repair is greatly reduced but persists with the potential for su... more aneurysm-related risk after open repair is greatly reduced but persists with the potential for subsequent anastomotic or true aneurysmal degeneration. Endovascular aneurysm repair with endoluminal placement of a stent graft provides a less invasive alternative to standard open surgery with reduced morbidity and more rapid patient recovery. 3-7 However, the long-term effectiveness of this approach compared with that of open surgery or with observation and no treatment is not well defined. This report will review the current clinical results of abdominal aortic aneurysm treatment with the AneuRx stent graft and consider issues related to its effectiveness against open surgery and the natural history of abdominal aortic aneurysms. We will also provide a current perspective on the worldwide use of the AneuRx stent graft for the treatment of patients with abdominal aortic aneurysms.
European Journal of Vascular and Endovascular Surgery, 2012
With great interest we have read the article by Kim and colleagues in this journal, 1 demonstrati... more With great interest we have read the article by Kim and colleagues in this journal, 1 demonstrating that intramuscular administration of human umbilical cord blood mononuclear cells (HCB-MNCs) enhances the number of capillaries, angiogenic gene expression and angiogenic factors in a canine hind limb ischemia model. We laud the attempt of the authors to translate their results into clinical practice, administering HCB-MNCs in patients with peripheral arterial occlusive disease (PAOD). However, this study raises some important questions. The authors put much emphasis on the potential development of graft-versus-host disease (GVHD). GVHD is known to occur after allogeneic stem cell transplantations, where donor lymphocytes encounter and offend the (immunodeficient) host's tissues, and has been reported as unusual adverse event after solid organ transplantations and blood transfusions, 2,3 always in states with impairment of the recipient's immune system. The article by Kim et al. however reports on intramuscular allogeneic HCB-MNC administration in fully immunocompetent individuals. The likelihood of developing a GVHD-like phenomenon in this setting is low, since donor derived allogeneic cells are delivered in a hostile environment with an active immune system. Induction of a widespread immunogenic reaction comparable to GVHD is therefore nearly impossible in our view. Rather, the recipient's immune response may lead to an inflammatory response and rapid removal of the infused cells, which may limit the potential therapeutic effect of allogeneic HCB-MNC. In that respect it is unfortunate that the authors do not provide any efficacy data from their clinical study. Although we agree that, to assess the ultimate efficacy of stem cell therapy, objective criteria and larger series are mandatory, evaluation of previous studies on autologous progenitor cell safety and efficacy in small series of patients with thromboangiitis obliterans 4,5 were able to show significant improvement of clinical parameters, such as transcutaneous oxygen pressure, pain, skin temperature and ulcer healing. Presentation of such efficacy data for allogeneic HCB-MNC would be a valuable addition to this paper. Altogether the authors propose an interesting therapeutic strategy for PAOD patients, however, as autologous approaches have already been shown promising and circumvent immunogenic complexities, we advocate the autologous approach and further improvement of these strategies.
Objective: Recent reports showed that the Endurant stent graft (Medtronic Cardiovascular, Santa R... more Objective: Recent reports showed that the Endurant stent graft (Medtronic Cardiovascular, Santa Rosa, Calif) is safe and effective for endovascular repair of abdominal aortic aneurysms (AAAs). However, due to its relatively recent introduction, only short-term follow-up data are available. This study presents the 4-year results using this device. Methods: All clinical data, including detailed anatomic information of the first 100 consecutive patients treated with the Endurant stent graft for an infrarenal AAA in three Dutch high-volume hospitals, were prospectively collected. Computed tomography angiography was routinely performed before the procedure, #1 month, and at 1 year postendovascular aneurysm repair. Thereafter, the imaging modality during yearly follow-up was individualized (duplex ultrasound imaging or computed tomography angiography). Patients were classified as within or outside the instructions for use (IFU) for analysis. Study end points were primary clinical success, overall and AAA-related mortality, and sac morphology changes and endoleak during follow-up. Estimates were obtained using Kaplan-Meier plots. Results: The study included 100 consecutive patients (88 men) with a median age of 74 years (interquartile range [IQR], 67-79 years) and median AAA diameter of 58 mm (IQR, 55-65 mm), between December 2007 and March 2009. Twenty patients (20%) were treated outside the IFU (18, outside proximal neck IFU, one outside iliac IFU, and one outside both IFUs). Median follow-up was 48 months (IQR, 36-53 months), and no patients were lost. One contained rupture was observed after 1.5 months due to graft infection. No patients had graft migration. Two type Ia endoleaks, 5 type Ib endoleaks, and 15 type II endoleaks were found. Primary clinical success was 97%, 90%, 84% and 77% at 1, 2, 3, and 4 years, respectively. Primary clinical success was comparable for patients treated within or outside IFU (P [ .20), although both patients outside iliac IFU needed a secondary iliac intervention. Over time, maximum aneurysm diameter decreased $5 mm, remained stable, and increased $5 mm in 58%, 32%, and 10% of the patients, respectively. All-cause mortality was 20% at 4 years, with a 3% AAA-related mortality. Conclusions: The 4-year follow-up data of the Endurant stent graft for AAA treatment shows its use results in a low AAArelated mortality with adequate prevention of rupture or aneurysm growth. Although patients with very challenging anatomy were treated in our series, primary clinical success rates were comparable for patients treated within and outside the IFU. However, both patients outside the iliac IFU needed a secondary iliac intervention. The knowledge of the present results may aid in improving outcomes in the future.
European Journal of Vascular and Endovascular Surgery, 2001
Objectives: to report the mid-term single-centre experience with the AneuRx self-expandable nitin... more Objectives: to report the mid-term single-centre experience with the AneuRx self-expandable nitinol stentgraft for endovascular aneurysm repair. Patients and Methods: between December 1996 and January 2000 a total of 128 patients were treated with an AneuRx bifurcated stentgraft. Of these, 77 patients had a minimum follow-up of 12 months. Patient operative and follow-up data were prospectively gathered. Results: two (3%) conversions were necessary. Median hospital stay was 3 days. One superficial wound infection occurred. Periprocedural (30 days) mortality was 5% (four patients). Three graft occlusions were noted of which two required treatment. Fifteen patients developed 18 endoleaks (six type 1, eight type 2 and four type 3). Type 1 and type 3 endoleaks were treated by extension cuffs. Four type 2 endoleaks were treated with embolisation or direct lumbar puncture. Two-year freedom from endoleak was 76%. Graft migration occurred in six cases, resulting in a 2-year freedom from migration of 90%, kinking only once. Conclusions: endovascular AAA treatment is feasible and so far mid-term results are without major problems. Extensive follow-up is essential as secondary problems may occur later. Long-term results are to be awaited.
Objectives: Endovascular aneurysm repair (EVAR) in hostile neck has been associated with adverse ... more Objectives: Endovascular aneurysm repair (EVAR) in hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and post-operative outcomes. Methods: This was a retrospective review of intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (> 60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated the optimal cutoff value of the aortic neck angle-length index. Patients were classified into two groups using latent profile analysis. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared. Results: 115 patients were included. Group 1(G1), aortic neck angle-length index ≤ 4.8, had 95 patients and Group 2 (G2), aortic neck ang...
l l Purpose: To ascertain if a percutaneously delivered venous valve bioprosthesis (PVVB) can be ... more l l Purpose: To ascertain if a percutaneously delivered venous valve bioprosthesis (PVVB) can be implanted in the porcine venous system and function without complications. Methods: The PVVB is a glutaraldehyde-preserved, valve-bearing venous xenograft su-tured inside a memory-coded nitinol frame (diameter 10, 12, or 14 mm). In 10 50-kg pigs, the external jugular vein was exposed, and a 16-F introducer sheath was positioned in the common iliac vein. One PVVB was inserted and deployed in each iliac vein under ¯uoro-scopic control. After PVVB implantation, all animals were randomly given either vitamin K antagonists (1±2 mg/d) (group I) or a combination of aspirin (150 mg/d) and clopidogrel (75 mg/d) (group II), which were shown in a preliminary pilot study to be the most effective anticoagulation regimens in the pig model. Ascending and descending completion phle-bograms were performed. PVVBs were evaluated with phlebography at 4 weeks to assess patency and competence; all PVVBs were ...
The benefit of catheter-directed thrombolysis for peripheral arterial occlusions is limited by he... more The benefit of catheter-directed thrombolysis for peripheral arterial occlusions is limited by hemorrhagic complications. Plasma fibrinogen level (PFL) has been suggested as a predictor of these hemorrhagic complications, but the accurateness of prediction is unknown. We summarized the available evidence on the predictive value of PFL for hemorrhagic complications after catheter-directed thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions. We systematically searched PubMed and Embase until January 2016 for peer-reviewed publications on adults undergoing thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions, assessing the predictive value of PFL for hemorrhagic complications. Two authors independently performed data extraction. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. In total, six studies (two randomized clinical trials and four cohort studies) reported on 613 patients unde...
Unplanned hospital readmissions following surgical interventions are associated with adverse even... more Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions. We identified all patients undergoing an infrainguinal endovascular intervention in the targeted vascular module of the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2014. Perioperative outcomes were stratified by symptom status (chronic limb-threatening ischemia [CLI] vs claudication). Patients who died during index admission and those who remained in the hospital after 30 days were excluded. Indications for unplanned readmission related to the index procedure were evaluated. Multivariable logistic regressio...
Patients on P2Y12 inhibitors may still develop thrombosis or bleeding complications. Tailored ant... more Patients on P2Y12 inhibitors may still develop thrombosis or bleeding complications. Tailored antiplatelet therapy, based on platelet reactivity testing, might reduce these complications. Several tests have been used, but failed to show a benefit of tailored antiplatelet therapy. This could be due to the narrowness of current platelet reactivity tests, which are limited to analysis of platelet aggregation after stimulation of the adenosine diphosphate (ADP)-pathway. However, the response to ADP does not necessarily reflect the effect of P2Y12 inhibition on platelet function in vivo. Therefore, we investigated whether measuring platelet reactivity toward other physiologically relevant agonists could provide more insight in the efficacy of P2Y12 inhibitors. The effect of in vitro and in vivo P2Y12 inhibition on αIIbβ3-activation, P-selectin and CD63-expression, aggregate formation, release of alpha, and dense granules content was assessed after stimulation of different platelet activa...
Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices... more Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices have been associated with acute hypertension, elevated pulse pressure, cardiac remodelling and reduced coronary perfusion. However, a systematic assessment of such cardiovascular effects of thoracic endovascular aortic repair (TEVAR) is missing. The CardiOvascular Remodelling following Endovascular aortic repair (CORE) study aims to (1) quantify cardiovascular remodelling following TEVAR and compare echocardiography against MRI, the reference method; (2) validate computational modelling of cardiovascular haemodynamics following TEVAR using clinical measurements, and virtually assess the impact of more compliant stent grafts on cardiovascular haemodynamics; and (3) investigate diagnostic accuracy of ECG and serum biomarkers for cardiac remodelling compared to MRI. This is a prospective, nonrandomised, observational cohort study. We will use MRI, CT, echocardiography, intraluminal pressur...
Background and aims: Peripheral arterial disease (PAD) is a common manifestation of atheroscleros... more Background and aims: Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis with an increasing incidence worldwide. The disease is still associated with high morbidity and mortality risks. Previous research in carotid arteries indicates that atherosclerotic plaque characteristics have stabilized over time in patients considered for surgery. It is currently unknown whether this timedependent stabilization occurs in ilio-femoral arteries as well. Our objective was to analyze whether local ilio-femoral atherosclerotic plaque characteristics have changed over time. Methods: 497 patients within the Athero-Express biobank who underwent primary endarterectomy of the iliac or femoral artery between 2002 and 2013 were analyzed. We investigated six histological plaque characteristics: calcification, collagen, fat content, intraplaque haemorrhage, macrophages and smooth muscle cells. Results: Over the course of 10 years, we observed a lower percentage of all plaque characteristics that are considered indicators of a vulnerable plaque, such as: plaques with a large lipid core from 37.9% to 14.9% and plaques with intraplaque haemorrhage from 69.0% to 34.8% when the two-year cohorts 2003e2004 and 2011e2012 were compared, respectively. Multivariable analyses showed that time-dependent changes occurred independently of changing procedural and patient characteristics. Conclusions: In this cohort of peripheral arterial disease patients undergoing primary endarterectomy, we observed a time dependent shift of plaque characteristics towards a less lipid rich lesion with less intraplaque haemorrhage. These findings indicate research in cardiovascular disease would benefit from contemporary patient characteristics and plaque specimens to optimize translational potential.
In patients with acute coronary syndrome, high platelet reactivity (PR) is associated with an inc... more In patients with acute coronary syndrome, high platelet reactivity (PR) is associated with an increased risk of secondary thrombotic events. However, in patients undergoing elective percutaneous coronary intervention (PCI), no association between high PR and outcome has been demonstrated. At present, the relation of PR and clinical symptoms is unknown. To examine the association of PR with clinical indication for diagnostic angiography (stable or unstable coronary artery disease [CAD]), taking into account the influence of P2Y 12 inhibitors. A platelet function score (PFS) was determined in 195 patients by quantifying fibrinogen binding and P-selectin expression with flow cytometry. We evaluated the PFS with clinical presentation of stable or unstable CAD, angiographic severity of CAD, and the incidence of cardiovascular events during 2 years of follow-up. All data were analyzed stratified by P2Y 12 inhibitor use (long-term and preprocedural versus none). Surprisingly, among non-P2Y 12 inhibitor users, the PFS was lower in patients with unstable CAD compared with stable CAD (5.6 AE 1.8 vs. 7.4 AE 1.6; p ¼ 0.001). Angiographic CAD severity showed no relation with PFS. The SYNTAX score tended to be inversely related with PFS: low PFS, 13.2 (IQR, 11.9-19.1); median PFS, 10.0 (IQR, 5.0-14.0); and high PFS, 8.0 (IQR, 5.0-13.0), without significance (p ¼ 0.304). Patients with low PFSs required more re-PCIs than those with median and high PFSs (11.1 vs. 4.7 vs. 0.0%, p ¼ 0.004). This association was modified for patients using P2Y 12 inhibitors. Among patients without P2Y 12 inhibitors undergoing coronary angiography, presentation of unstable CAD is independently associated with lower PR.
Diabetes mellitus (DM) is associated with peripheral arterial disease (PAD) and leads to worse cl... more Diabetes mellitus (DM) is associated with peripheral arterial disease (PAD) and leads to worse clinical outcome compared with patients without DM. The objective of this study was to determine the impact of DM on iliofemoral artery plaque characteristics and to examine secondary clinical outcomes in patients with DM and PAD undergoing surgical revascularization. We analyzed 198 patients with and 453 patients without DM from the Athero-Express biobank, a prospective ongoing biobank study, who underwent endarterectomy of the femoral or iliac artery between 2002 and 2013. Seven histologic plaque characteristics (calcification, collagen, lipid core, intraplaque hemorrhage, macrophages, microvessels, and smooth muscle cells) and secondary clinical outcome were compared. Composite outcome consisted of any of the following secondary manifestations of cardiovascular disease: stroke, myocardial infarction, cardiovascular death, or peripheral intervention. In addition, target vessel revascular...
This study evaluated the concept of percutaneous closure of insufficient veins using the VeinScre... more This study evaluated the concept of percutaneous closure of insufficient veins using the VeinScrew principle. The VeinScrew is designed to place a spring-shaped implant that contracts and clamps around the vein. The ability of the device to occlude adequately was tested in a bench model experiment. The feasibility of accurate placement and adequate venous occlusion was evaluated in an animal experiment and in a human cadaveric experiment. The VeinScrew implant occluded up to a pressure of 135 mmHg. In vivo studies confirmed that deployment was challenging but technically feasible, and subsequent phlebography showed closure of the vein. The cadaveric study showed that percutaneous placement of the evolved VeinScrew around the great saphenous vein was feasible and accurate. The current studies show the feasibility of the VeinScrew concept. Future developments and translational studies are necessary to determine the potential of this technique as a new option in the phlebologist's ...
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, Jan 8, 2016
To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic ... more To investigate the total fluoroscopy time and radiation exposure dose during endovascular aortic repairs using mobile, fixed, or fixed C-arms with 3-dimensional image fusion (3D-IF). A systematic search was performed to identify original articles reporting fluoroscopy time (FT) and the kerma area product (KAP) during endovascular aortic repairs. Data were grouped by noncomplex or complex (fenestrated, branched, or chimney) repairs and stratified by type of C-arm. The search identified 27 articles containing 51 study groups (35 noncomplex and 16 complex) that included 3444 patients. Random-effects meta-analysis and meta-regression models were used to calculate the pooled mean estimates of KAP and FT, as well as any effect of equipment or type of intervention. Results are presented with the 95% confidence interval and the statistical heterogeneity (I(2)). Within the noncomplex procedure studies, a significant (p<0.001) increase was found in the pooled mean KAP estimate in the fixed...
Background: Endovascular treatment of peripheral arterial disease (PAD) still yields unsatisfacto... more Background: Endovascular treatment of peripheral arterial disease (PAD) still yields unsatisfactory patency rates. Recent new developments include the use of bioresorbable stents. The objective of this study was to provide an overview of currently available data on the use of bioresorbable stents in lower limb PAD and to summarize the needs for future research focus. Methods: A systematic search in the databases of MEDLINE, Embase, and the Cochrane Library was performed. Studies using predefined inclusion and exclusion criteria were included and critically appraised by two independent reviewers. Inclusion criteria were (1) original data on (2) bioresorbable stents in (3) lower limb arteries including the iliac tract. Primary end points were safety and feasibility of bioresorbable stents, including 30-day adverse events. Secondary end points included radial force, bioresorption process, long-term primary and secondary patency, and clinical outcomes, such as amputation rate, Rutherford category, and ankle-brachial index improvement. Results: Seven published studies with a total of 316 patients were included, and five conference abstracts including 272 patients were assessed. Median follow-up time was 12 months. Overall technical success rate was 99% (range, 95.0%-100%). The 30-day adverse event rates were reported in 5.0% of patients (range, 0%-13.3%); these included one death, two major amputations, and seven reinterventions. Mean primary patency rate was 61.6% in the femoral arteries (range, 32.1%-80.0%) after 6 to 12 months compared with 50.3% in below-the-knee lesions (range, 31.8%-92.9%). Secondary patency rates were 91.5% (range, 84%-97.1%) and 72.1% (range, 62.9%-100%), respectively. The 1-year amputation rate was 3.0% in the whole group (range, 0%-12.4%). Conclusions: Experience with the use of bioresorbable stents in PAD is still limited and is investigated only in small studies. The use of bioresorbable stents in PAD appears to be feasible and safe. With current published results, we are unable to fully answer all of the questions about the future use of bioresorbable stents in PAD, and use should be limited to study-related cases in PAD.
The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q f... more The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007-2010 in the Netherlands. In November 2009, an ongoing screening program for Q fever was initiated. Patients with abdominal aortic and/or iliac disease were screened for presence of IgM and IgG antibodies to phase I and II antigens of Coxiella burnetii using immunofluorescence assay and presence of C. burnetii DNA in sera and/or vascular wall tissue using polymerase chain reaction (PCR). A total of 770 patients with abdominal aortic and/or iliac disease were screened. Antibodies against C. burnetii were detected in 130 patients (16.9%), of which 40 (30.8%) patients showed a serological profile of chronic Q fever. Three patients presented with acute Q fever, one of which developed to chronic Q fever over time. The number of aneurysm-related acute complications in patients with chronic Q fever was significantly higher compared to patients negative for Q fever (p = 0.013); 9.0% (30/333) vs. 30.0% (6/20). Eight out of 46 patients with past resolved Q fever (8/46, 17.4%) presented with aneurysm-related acute complications (no significant difference). The prevalence of chronic Q fever in C. burnetii seropositive patients with abdominal aortic and/or iliac disease living in an epidemic area in the Netherlands is remarkably high (30.8%). Patients with an aneurysm and chronic Q fever present more often with an aneurysm-related acute complication compared to patients without evidence of Q fever infection.
Diabetes is a risk factor for atherosclerotic disease but negatively associated with the developm... more Diabetes is a risk factor for atherosclerotic disease but negatively associated with the development and progression of abdominal aortic aneurysm (AAA). Advanced glycation end products (AGEs) are increased in diabetes and renders the vascular matrix more resistant to proteolysis. We assessed the concentration of AGEs in AAA biopsies obtained from diabetic and nondiabetic patients and hypothesized that (nonenzymatic) glycation of AAA tissue protects against proteolytic breakdown of collagen. AAA biopsies were collected from 30 diabetic and 30 matched nondiabetic AAA patients at the time of open repair. Aortic control samples from 10 nondiabetic and 16 diabetic patients were collected, and concentrations of the AGE cross-link pentosidine was measured. Furthermore, noncross-linking AGEs (adducts), as well as proteolytic enzymes known to play a role in aneurysm development (matrix metalloproteinase [MMP]-2, MMP-9, cathepsin B and S) were quantified. Ex vivo, nondiabetic AAA biopsies wer...
Traditional carotid endarterectomy is considered to be the standard technique for prevention of a... more Traditional carotid endarterectomy is considered to be the standard technique for prevention of a new stroke in patients with a symptomatic carotid stenosis. Use of plexus anesthesia or general anesthesia in traditional carotid endarterectomy is, to date, not unequivocally proven to be superior to one other. A systematic review was needed for evaluation of benefits and harms to determine which technique, plexus anesthesia or general anesthesia is more effective for traditional carotid endarterectomy in patients with symptomatic carotid stenosis. Methods: The review was conducted according to our protocol following the recommendations of Cochrane and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were updated on the October 1, 2020. We did not find any randomized clinical trial comparing plexus anesthesia and general anesthesia in carotid endarterectomy with patch angioplasty matching our protocol criteria in patients with a symptomatic and significant (≥50%) carotid stenosis. Conclusions: Based on the current, high risk of bias evidence, we concluded there is a need for new randomized clinical trials with overall low risk of bias comparing plexus anesthesia with general anesthesia in carotid endarterectomy with patch closure of the arterial wall in patients with a symptomatic and significant (≥50%) stenosis of the internal carotid artery. Protocol unique identification number (UIN): CRD42019139913, (https://www.crd.york.ac.uk/prospero/displa y_record.php?RecordID=139913);
This study addresses the use of decision analysis and Markov models to make contemplated decision... more This study addresses the use of decision analysis and Markov models to make contemplated decisions for surgical problems. Decision analysis and decision modeling in surgical research are increasing, but many surgeons are unfamiliar with the techniques and are skeptical of the results. The goal of this review is to familiarize surgeons with techniques and terminology used in decision analytic papers, to provide the reader a practical guide to read these papers, and to ensure that surgeons can critically appraise the quality of published clinical decision models and draw well founded conclusions from such reports.First, a brief explanation of decision analysis and Markov models is presented in simple steps, followed by an overview of the components of a decision and Markov model. Subsequently, commonly used terms and definitions are described and explained, including quality-adjusted life-years, disability-adjusted life-years, discounting, half-cycle correction, cycle length, probabil...
aneurysm-related risk after open repair is greatly reduced but persists with the potential for su... more aneurysm-related risk after open repair is greatly reduced but persists with the potential for subsequent anastomotic or true aneurysmal degeneration. Endovascular aneurysm repair with endoluminal placement of a stent graft provides a less invasive alternative to standard open surgery with reduced morbidity and more rapid patient recovery. 3-7 However, the long-term effectiveness of this approach compared with that of open surgery or with observation and no treatment is not well defined. This report will review the current clinical results of abdominal aortic aneurysm treatment with the AneuRx stent graft and consider issues related to its effectiveness against open surgery and the natural history of abdominal aortic aneurysms. We will also provide a current perspective on the worldwide use of the AneuRx stent graft for the treatment of patients with abdominal aortic aneurysms.
European Journal of Vascular and Endovascular Surgery, 2012
With great interest we have read the article by Kim and colleagues in this journal, 1 demonstrati... more With great interest we have read the article by Kim and colleagues in this journal, 1 demonstrating that intramuscular administration of human umbilical cord blood mononuclear cells (HCB-MNCs) enhances the number of capillaries, angiogenic gene expression and angiogenic factors in a canine hind limb ischemia model. We laud the attempt of the authors to translate their results into clinical practice, administering HCB-MNCs in patients with peripheral arterial occlusive disease (PAOD). However, this study raises some important questions. The authors put much emphasis on the potential development of graft-versus-host disease (GVHD). GVHD is known to occur after allogeneic stem cell transplantations, where donor lymphocytes encounter and offend the (immunodeficient) host's tissues, and has been reported as unusual adverse event after solid organ transplantations and blood transfusions, 2,3 always in states with impairment of the recipient's immune system. The article by Kim et al. however reports on intramuscular allogeneic HCB-MNC administration in fully immunocompetent individuals. The likelihood of developing a GVHD-like phenomenon in this setting is low, since donor derived allogeneic cells are delivered in a hostile environment with an active immune system. Induction of a widespread immunogenic reaction comparable to GVHD is therefore nearly impossible in our view. Rather, the recipient's immune response may lead to an inflammatory response and rapid removal of the infused cells, which may limit the potential therapeutic effect of allogeneic HCB-MNC. In that respect it is unfortunate that the authors do not provide any efficacy data from their clinical study. Although we agree that, to assess the ultimate efficacy of stem cell therapy, objective criteria and larger series are mandatory, evaluation of previous studies on autologous progenitor cell safety and efficacy in small series of patients with thromboangiitis obliterans 4,5 were able to show significant improvement of clinical parameters, such as transcutaneous oxygen pressure, pain, skin temperature and ulcer healing. Presentation of such efficacy data for allogeneic HCB-MNC would be a valuable addition to this paper. Altogether the authors propose an interesting therapeutic strategy for PAOD patients, however, as autologous approaches have already been shown promising and circumvent immunogenic complexities, we advocate the autologous approach and further improvement of these strategies.
Objective: Recent reports showed that the Endurant stent graft (Medtronic Cardiovascular, Santa R... more Objective: Recent reports showed that the Endurant stent graft (Medtronic Cardiovascular, Santa Rosa, Calif) is safe and effective for endovascular repair of abdominal aortic aneurysms (AAAs). However, due to its relatively recent introduction, only short-term follow-up data are available. This study presents the 4-year results using this device. Methods: All clinical data, including detailed anatomic information of the first 100 consecutive patients treated with the Endurant stent graft for an infrarenal AAA in three Dutch high-volume hospitals, were prospectively collected. Computed tomography angiography was routinely performed before the procedure, #1 month, and at 1 year postendovascular aneurysm repair. Thereafter, the imaging modality during yearly follow-up was individualized (duplex ultrasound imaging or computed tomography angiography). Patients were classified as within or outside the instructions for use (IFU) for analysis. Study end points were primary clinical success, overall and AAA-related mortality, and sac morphology changes and endoleak during follow-up. Estimates were obtained using Kaplan-Meier plots. Results: The study included 100 consecutive patients (88 men) with a median age of 74 years (interquartile range [IQR], 67-79 years) and median AAA diameter of 58 mm (IQR, 55-65 mm), between December 2007 and March 2009. Twenty patients (20%) were treated outside the IFU (18, outside proximal neck IFU, one outside iliac IFU, and one outside both IFUs). Median follow-up was 48 months (IQR, 36-53 months), and no patients were lost. One contained rupture was observed after 1.5 months due to graft infection. No patients had graft migration. Two type Ia endoleaks, 5 type Ib endoleaks, and 15 type II endoleaks were found. Primary clinical success was 97%, 90%, 84% and 77% at 1, 2, 3, and 4 years, respectively. Primary clinical success was comparable for patients treated within or outside IFU (P [ .20), although both patients outside iliac IFU needed a secondary iliac intervention. Over time, maximum aneurysm diameter decreased $5 mm, remained stable, and increased $5 mm in 58%, 32%, and 10% of the patients, respectively. All-cause mortality was 20% at 4 years, with a 3% AAA-related mortality. Conclusions: The 4-year follow-up data of the Endurant stent graft for AAA treatment shows its use results in a low AAArelated mortality with adequate prevention of rupture or aneurysm growth. Although patients with very challenging anatomy were treated in our series, primary clinical success rates were comparable for patients treated within and outside the IFU. However, both patients outside the iliac IFU needed a secondary iliac intervention. The knowledge of the present results may aid in improving outcomes in the future.
European Journal of Vascular and Endovascular Surgery, 2001
Objectives: to report the mid-term single-centre experience with the AneuRx self-expandable nitin... more Objectives: to report the mid-term single-centre experience with the AneuRx self-expandable nitinol stentgraft for endovascular aneurysm repair. Patients and Methods: between December 1996 and January 2000 a total of 128 patients were treated with an AneuRx bifurcated stentgraft. Of these, 77 patients had a minimum follow-up of 12 months. Patient operative and follow-up data were prospectively gathered. Results: two (3%) conversions were necessary. Median hospital stay was 3 days. One superficial wound infection occurred. Periprocedural (30 days) mortality was 5% (four patients). Three graft occlusions were noted of which two required treatment. Fifteen patients developed 18 endoleaks (six type 1, eight type 2 and four type 3). Type 1 and type 3 endoleaks were treated by extension cuffs. Four type 2 endoleaks were treated with embolisation or direct lumbar puncture. Two-year freedom from endoleak was 76%. Graft migration occurred in six cases, resulting in a 2-year freedom from migration of 90%, kinking only once. Conclusions: endovascular AAA treatment is feasible and so far mid-term results are without major problems. Extensive follow-up is essential as secondary problems may occur later. Long-term results are to be awaited.
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Papers by Frans Moll