Vascular Surgery

Objectives: P-selectin inhibition has been found to limit venous thrombosis. We hypothesize that elevated levels of P-selectin will amplify thrombosis, mediated by procoagulant microparticles (MPs). Methods: Male mice (Mus musculus, n659), 20 to 25 grams, underwent IVC ligation to induce thrombosis. Groups consisted of wild type (WT) C57BL/6 controls, mice with high circulating levels of soluble P-selectin (^CT), P-selectin gene-interrupted knockout mice (PKO), and E-and P-selectin gene-interrupted mice (EPKO). Additional groups were used to evaluate the ability of a P-sel antagonist (rPSGL-Ig) and an antibody directed against PSGL-1 to downregulate the effects of P-sel in^CT mice and WT mice administered soluble P-sel at time of thrombosis. Animals were sacrificed on days 2 and 6 after IVC ligation. Thrombus mass (TM), vein wall morphometrics, and serum leukocyte/platelet microparticles (MPs) were evaluated by means of double-stained fluorescence-activated cell scanning analysis, and soluble P-and E-sel protein determination by ELISA. Results: At days 2 and 6 in phase I of the experiment, significant differences (P < .01) in TM were noted between groups, with^CT animals having the largest thrombi (50% and 57% increase in TM compared to WT at days 2 and 6) while EPKO mice had the smallest thrombi. Statistically, greater levels of neutrophils and total inflammatory cells were noted in the vein walls of^CT animals at day 2 compared with WT and PKO animals. A significant difference was noted between^CT and EPKO for neutrophils, monocytes, and total inflammatory cells, also at day 2. At day 6, the only statistically significant difference was found for monocytes, with a higher number in the^CT animals than in WT animals. The evaluation of MPs revealed that the^CT mice had a mixed leukocyte (MAC-1) and platelet (CD41) MP population that was also present in WT and PKO mice on day 2 and day 6. EPKO mice revealed a primarily platelet-derived MP population. Of interest, the^CT mice with the highest TM showed a high amount of mean channel fluorescence for MAC-1 (phycoerythrin) antibody, indicative of leukocyte MPs.^CT mice revealed statistically higher levels of soluble P-selectin at days 2 and 6. In phase 2, an antibody directed against PSGL-1 was more effective than rPSGL-Ig in decreasing TM and limiting leukocyte-derived MP fluorescence. Conclusions: This study demonstrates that high circulating levels of P-selectin are associated with increased thrombosis, whereas a lack of P-selectin and E-selectin is associated with a lessening of thrombosis. Additionally, leukocyte MPs are associated with venous thrombus formation. These data suggest the importance of selectins to venous thrombogenesis and show that P-selectin and leukocyte-derived MPs should be good targets to limit venous thrombus formation. (J Vasc Surg 2003;38:1075-89.)

Kinked extracranial carotid and vertebral arteries are observed in 10% to 16% of cerebral angiograms. The hemodynamic significance of some kinked carotid arteries has been shown by investigators who documented oculoplethysmographic and angiographic differences accompanying flexion, extension, or rotation changes of the neck and head. In the 3-year period ending November 1985, we performed operations on seven patients to correct six kinked internal carotid arteries and one kinked vertebral artery at the C-2 level. The final decision regarding optimal operative technique was determined during operation, after observing the relative lengths of dissected arteries, envisioning the results of the procedures selected. We performed five segmental resections and end-to-end anastomoses (one vertebral, two common carotid, and two internal carotid arteries). Transection of the internal carotid artery with reirnplantation into the side of the common carotid artery was performed twice. All patients became asymptomatic up to 4 years, irrespective of head and neck positions. There were no complications or deaths in these patients. This experience suggests that arterial kinks may constitute tenable indications for operative treatment in patients with transient cerebral ischemia who lack typical stenotic or ulcerative plaques to account for their symptoms. Kinked arteries can be corrected safely and effectively by appropriate surgical procedures.

Background: The use of endovascular aneurysm repair (EVAR) in abdominal aortic aneurysm is limited by neck configuration and angulation. Using stent grafts outside the instructions for use may result in failure and higher endoleak rate. Treatment and prevention of endoleaks with additional use of uncovered stents in the neck have been reported in single cases and small series. Methods: In cases with high angulated necks of >90 degrees, we used an uncovered nitinol stent (E-XL; Jotec, Hechingen, Germany) to reduce the angulation and to make standard EVAR possible. We used it before EVAR or after EVAR and in a sandwich technique. In patients with new or persistent proximal endoleaks (type IA), it was used to seal the proximal neck. In the thoracic aorta, we used the E-XL stent to treat coarctations in combination with covered stents. Results: In highly angulated necks of >90 degrees, it was possible to reduce the angulation to a normal range so that successful standard EVAR was possible. This works with polyester and polytetrafluoroethylene grafts. If we have a long neck, we try to straighten the anatomy with stiff wires so that we can implant the E-XL in the implanted stent graft. In short necks, we prefer to prepare the neck with the stiff wires and the E-XL before stent graft implantation. This sequence shows good performance with moderate residual angulation and good sealing of the stent graft. If we can show in type IA endoleaks that with ballooning we can occlude the endoleak, we use the E-XL to increase proximal sealing with good results. The coarctation treatment shows excellent results with minimal or no residual stenosis. We use it in connection with covered stents to avoid the risk of rupture and bleeding. Conclusions: Big self-expanding nitinol stents like the E-XL are useful tools for treatment of aortic diseases. They can modify the shape of the aorta to create conditions for EVAR; we can use them to improve the adaptation to the aortic wall in endoleaks as an alternative to endoanchors. The open-cell design allows coverage of the renal and visceral arteries without affecting the flow; later interventions are possible. In coarctation, the radial force of the stent keeps it open and in position; here we can even cover the left subclavian artery if necessary without negative effects.

Non-giant cell arteritis disease of the superficial temporal artery (STA) is rare, appearing only as case reports in the literature. There were nine patients with STA pathology. STA aneurysm (n ‫؍‬ 1), pseudoaneurysm (n ‫؍‬ 4), thrombosis (n ‫؍‬ 1), and arteriovenous malformation (n ‫؍‬ 3). Four patients had ligation and excision, three had percutaneous interventions and one had a combination of both. All patients had immediate technical success and eight of the nine total patients had follow-up. We present a variety of ways to approach these unusual pathologies with percutaneous and open techniques demonstrating very good early outcome

Injuries of the abdominal visceral vessels are uncommon but devastating entities resulting in extremely high rates of mortality. The most common cause of abdominal vascular injuries is penetrating trauma, accounting for 90% to 95% of these injuries. In contrast, blunt trauma accounts for 5% to 10% of all abdominal vascular lesions. Although traumatic injury to the celiac artery is among the rarest of all vascular injuries, mortality can be as high as 75%. We report a 66-year-old patient who sustained multiple injuries in a motor vehicle crash. The initial whole-body computed tomography (CT) scan revealed a combination of severe brain injury and bilateral thoracic lesions. On day 6 after the accident, the patient's clinical situation deteriorated rapidly. At this time, the abdominal arterial CT scan showed a dissection of the celiac artery. Therapeutic anticoagulation was not feasible because of the intracranial hemorrhage. Also the patient's clinical situation worsened so rapidly that interventional therapy, including surgical and endovascular treatment, could not be performed. Finally, the patient died of fulminant hepatic failure, therefore not surviving a potentially treatable injury. The diagnosis of celiac artery dissection in this patient was significantly delayed because the initial trauma CT protocol did not include an arterial phase of the abdominal vessels. ( J Vasc Surg 2007;46:576-80.)

Repair of the VA has evolved in the last decade. It began as an uncommon operation used in a minute percentage of patients with cerebrovascular disease. At that time many neurologists and vascular surgeons viewed these reconstructions with skepticism, doubting that they could influence the neurologic outcome of these patients or even if they were needed at all.

A 36-year-old woman with chronic venous insufficiency of the lower extremities underwent successful venous valve reconstruction with prosthetic bovine monocusp patches in the superficial femoral and great saphenous veins. Postoperative valvular competence is evident in Doppler studies, photoplethysmography, phlebography, and clinical improvement after a 15-month follow-up.

The expansion of an abdominal aortic aneurysm sac after conventional repair has been rarely described. All cases in the literature have been associated with polytetrafluoroethylene grafts and perigraft seromas. We present a patient with a recurrent, symptomatic periaortic graft seroma after conventional repair. The etiology of this problem along with its potential increasing significance in the endovascular era is reviewed.

Objective: Although infection following carotid endarterectomy is rare, consequences of this seldom seen complication can be devastating. Polyester, polytetrafluoroethylene (PTFE), and vein patches have all been used by many institutions for patch angioplasty, each with reported cases of infection following surgery. Our institution has preferentially used PTFE for the majority of cases, and here, we report our experience with postoperative infection following endarterectomy over the last decade. Methods: From January 2000 through July 2009, we treated infections following carotid endarterectomy in 25 patients. Results: Of the 25 patients undergoing treatment for postoperative infection, 21 had PTFE patches placed during the initial surgery. The remaining four consisted of two polyester patches and two bovine pericardial patches. Twenty-three of the 25 initial endarterectomies were performed at our institution, and the other two were referrals. The majority of cases (56%) were due to gram-positive organisms, with only two cases being polymicrobial. The interval from the original surgery to clinical presentation ranged from 7 days to 85 months, with 20 patients (80%) presenting within 60 days of the first operation. Thirteen patients underwent incision and drainage with antibiotics, and 12 patients underwent definitive surgical treatment. Four received patch excision with vein patch angioplasty, four received patch excision with vein interposition, and four received sternocleidomastoid flaps. The 30-day stroke rate was 8%, and the freedom from recurrent infection was 100% at a mean follow-up of 32 months. Conclusion: Infection following carotid endarterectomy occurs <1% of the time; however, the potential for morbidity is significant. Our results show that most infections following PTFE patch angioplasty occur in the early postoperative period (<60 days) and that simple drainage with antibiotics may be an adequate form of treatment in select cases. ( J Vasc Surg 2011;53:1473-7.)

Abstract: As a group, heavy metals include both those essential for normal biological functioning (e.g., Cu and Zn), and nonessential metals (e.g., Cd, Hg, and Pb). Both essential and nonessential metals can be present at concentrations that disturb normal biological functions, and which evoke cellular stress responses. The cellular targets for metal toxicity include tissues of the kidney, liver, heart, and the immune response and nervous systems. Intriguingly, manipulations of specific metals, their reservoirs, and the cellular stress response can have therapeutic effects on certain diseases. In this minireview, we will consider both the biological responses to stressful levels of heavy metal cations, and experimental and clinical manipulations of these cations as a means to improve human health parameters.

Purpose: The purposes of this study were to evaluate the long-term results of different autogenous conduits used for infrainguinal bypass when ipsilateral greater saphenous vein (IGSV) is absent or inadequate and to determine the impact on the contralateral lower extremity. Methods: The study was performed as a retrospective evaluation of a prospective vascular registry together with review of patient records and telephone follow-up. Results: From January 1990 to June 2000, 226 autogenous infrainguinal reconstructions were performed in 203 patients without adequate IGSV. The patients consisted of 128 men and 98 women, with a mean age of 69 years. Prevalent risk factors included diabetes (51%) and prior coronary bypass (46%). Limb salvage was the predominant indication (93%), and 59% of the procedures were secondary reconstructions. All bypasses were completed with autogenous vein, which included contralateral greater saphenous vein (CGSV; 31%), single-segment lesser saphenous vein (5%), single-segment arm vein (19%), and autogenous composite vein (45%). Bypasses were performed to the tibial and pedal arteries in 84% of the cases. The 30-day mortality and graft occlusion rates were 1% and 9%, respectively. The overall postoperative morbidity rate was 24%, with a 7% rate of major complications. Follow-up was complete in 95% of patients over a mean period of 24 months (range, 0.1 to 106 months). The 5-year primary patency rates were significantly better for CGSV compared with autogenous composite vein grafts (61% ؎ 7% versus 39% ؎ 6%; P < .009). The 5-year secondary patency (60% to 73%) and limb salvage (78% to 81%) rates did not differ significantly between the three groups. Follow-up of the contralateral lower limb revealed that nine of 226 limbs (4%) were amputated at a mean of 36 months after the ipsilateral bypass. The overall 5-year contralateral limb preservation rate was 90% ؎ 3%. Contralateral vein harvest and the presence of diabetes did not affect the need for bypass or amputation of the contralateral limb. Conclusion: For most patients with inadequate IGSV, the CGSV is the alternative conduit of choice because of its length, superior performance, ease of harvest, and minimal risk to the donor limb. (J Vasc Surg 2002;35:1085-92.) From the Division of Vascular Surgery, Brigham and Women's Hospital, Harvard Medical School. Competition of interest: nil.

A 31-year-old woman with neurofibromatosis type I (NF-I) came to our hospital with hypotension and abdominal pain. A computed tomography (CT) scan showed blood in the retroperitoneum and two saccular aneurysms in the superior mesenteric artery (SMA). The largest measured 2.5 cm in diameter. She was treated with placement of a covered stent in the SMA, and both aneurysms were excluded from the systemic circulation. Arterial aneurysms are rare in this disease, and rupture of an SMA aneurysm in this context had been reported only once. We report an unusual case of a contained rupture of an SMA aneurysm associated with NF-I, successfully treated with a covered stent.

Objective: Minimally invasive methods (MIMs) are now available for the management of visceral artery aneurysms and pseudoaneurysms (visceral artery aneurysms [VAA]). The purpose of this study was to review our 10-year experience with the MIM of treating VAA. Methods: All patients evaluated from June 1999 to June 2009 with VAAs were reviewed. Demographics, therapy, and results were analyzed. Results: MIM was attempted in 185 aneurysms in 176 patients. Initial intervention was successful in 98% of aneurysms. Sixty-three (34%) aneurysms were located in the splenic artery, 56 (30%) in the hepatic, 28 (15%) in the gastroduodenal, 16 (8.6%) in the pancreaticoduodenal, six (3.2%) in the superior mesenteric, four (2.1%) in the gastric, four (2.1%) in the celiac, four (2.1%) in the gastroepiploic, two (1%) in the inferior mesenteric, and one (0.5%) in the middle colic artery. Pseudoaneurysms were more common than true aneurysms (64% vs 36%). Bleeding was the indication for intervention in 86 aneurysms (46%). Initial treatment was successful in 177 aneurysms (98%). Reintervention was required in five (3%) aneurysms within 30 days. Coiling was used alone in 139 aneurysms (75%) and in combination with at least one other technique in 20 (11%) cases. Thirty-day aneurysm-related mortality was 3.4% (six deaths). Five additional deaths occurred during 30-day follow-up, although none was related to complications of the aneurysms (2.8%). Conclusions: MIM for visceral artery aneurysms can be used alone or in combination to effectively treat VAAs in elective or emergent conditions. ( J Vasc Surg 2011;53:966-70.)

The study was conducted to demonstrate improved survival (30-day mortality) after the introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms (rAAA). Numerous authors have successfully demonstrated reduced mortality in patients with rAAA using endovascular techniques. Comparison of endovascular aneurysm repair (EVAR) with open repair for rAAA may be misleading, however, because EVAR cannot be performed on all patients, and selection bias may explain the superior performance of any given surgical or endovascular strategy. We developed a model to predict mortality in patients before the introduction of EVAR (preprotocol population), applied this model to predict 30-day mortality among prospective patients (postprotocol population), and compared observed vs expected results. Methods: We assessed 126 patients with rAAA. Primary outcome was 30-day mortality. Potential confounding variables were age, sex, presurgical lowest recorded systolic blood pressure (SBP), and glomerular filtration rate (GFR). A logistic regression model incorporating significant confounders was used to evaluate changes in 30-day mortality for all patients with rAAA after introduction of the EVAR protocol. Separate logistic regressions were done to compare 30-day mortality for preprotocol vs patients receiving EVAR and preprotocol vs patients receiving postprotocol open repair. Cumulative sum (CUSUM) analysis was used to assess shifts in the performance of the rAAA program over time.

Background: Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high-risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial. Methods: The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N 5 52) or no PR (N 5 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N 5 62) or severe claudication (N 5 47). The composite end-point of death and nonfatal myocardial infarction (MI) was determined by an intention-to-treat analysis following randomization. Results: The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P 5 0.08, odds ratio 5 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06-3.43; P 5 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99-3.23; P 5 0.07). Conclusions: In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status. V C 2010 Wiley-Liss, Inc.

To determine whether a percutaneous vascular intervention (PVI) combined with supplemental supervised exercise therapy (SET) is more effective than a PVI alone in improving walking ability in patients with symptomatic peripheral arterial disease (PAD).

Abstract: A total of 13 cadavers (12 men and 1 women) of different age group were used for the study with the purpose to determine the prevalence of femoral vein duplication. Lower limb regions (26 sides) were carefully dissected as per the standard dissection procedure. Femoral vein (unitruncular) was found in 96.15% of specimen. Bitruncular configurations (total bifidity) was found in a male cadaver of 75 years of age (3.85%). In the right lower limb, 6.5 cms below the inguinal ligament the femoral vein - lateral ramus received the lateral circumflex femoral vein, and the medial circumflex femoral vein, and the lateral and medial ramii formed a common venous trunk. Knowledge of the truncular venous variations is important to recognize and avoid potential errors in diagnosis of deep venous thrombosis of the femoral vein, in the case of an occluded duplicated trunk.

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst ...

Dr Cameron should be proud of his 6th edition of "Current surgical therapy." This text meets the objective of providing up-to-date information on therapeutic options for a broad range of subject material. When my vascular fellow saw that I was reading this text, he requested that I consider exchanging my 6th edition for his 4th edition, which he had judged to be excellent, because he wanted an updated version.

This case report described a patient of Behçet disease (BD)-related vascular lesions that initially presented as occlusion of superior vena cava (SVC) without any evidence of thrombosis. The patient was treated first by percutaneous transluminal angioplasty and stent implantation, and he developed thrombosis in the stent and then received open bypass operation. Pathologic examination of the SVC specimen and the postoperative manifestations revealed that the underlying cause of his symptoms as BD. Afterward, methylprednisolone plus anticoagulant therapy was routinely given, which relieved the symptoms of the patient. ( J Vasc Surg 2012;55:1488-91.)

Purpose: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. Methods: The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. Results: Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P = .023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P = .16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P = .044). Conclusions: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial

CLI patients face a dismal prognosis with one year mortality up to 30% Infra-popliteal BS is a demanding procedure with poor long-term survival. A minimally invasive therapy with equivalent results would be more appropriate. SIA is easy to execute; requires short hospital admission and lower costs. Primary endpoints are sustained clinical improvement (SCI) and amputation free survival (AFS). Secondary endpoints are BinaryRrestenosis (BR) rate, Freedom from target lesion revascularisation (TLR), risk of Major Adverse Clinical Events (MACE), Quality Time Without Symptoms of disease or Toxicity of Treatment (Q-TWiST) and cost-effectiveness. From 2002From -2007From , 1076 patients were referred with PVD. 334 primary procedures (SIAϭ206, BSϭ128) in 309 patients (NSIAϭ190, NBSϭ119) with TASC C and D lesions were prospectively compared Mean age (SIA 73ϩ/Ϫ13yrs vs. BS 70ϩ/Ϫ14yrs, pϭ0.127), and co-morbidity severity scores (PϾ0.05) were similar between groups. 5-year SCI was 82.8% for SIA and 68.2% for BS ( pϭ0.106 hϭ0.65, 95%CIϭ[0.38-1.11]). 5-year all-cause survival was similar for SIA (78.6%) and BS (80.1%), pϭ0.7343. 5-year AFS was comparable (SIA 72.9% vs. BS 71.2%, pϭ0.9765). Hyper-fibrinogenaemia and elevated CRP had negative effect on AFS (pϭ0.009, RR2.4, 95%CIϭ1.2-4.6 and pϭ0.019, RR1.02, 95%CIϭ1.01-1.04, respectively). 5-year freedom from BR were (SIA72.8% vs.BS65.3%, pϭ0.7001). Hyper-homocysteine had significant adverse effect on risk of BR for SIA (pϭ0.008) and BS (pϭ0.019) Results were not effected by stent use (35%, pϭ0.780) or mean number of stents (RR1.3, pϭ0.330). 5-year freedom from TLR was (SIA 85.9% vs. BS 72.1%, pϭ0.262). Risk of MAE (PϽ0.002) and length of hospital stay (LOSSIA14ϩ/Ϫ16days vs. LOSBS24ϩ/Ϫ23days, PϽ0.0001) were significantly reduced with SIA. Q-TWiST significantly improved (PϽ0.001) and cost per QALY (SIA: €5,663 vs BS: €9,172, PϽ0.05) reduced with SIA. 5-year risk of re-intervention (pϾ0.05) and mean number of procedures (SIA 1.19 vs. BS 1.10, pϭ0.078) were similar. BS is an independent risk factor for MACE. 5-year Freedom from MACE in SIA is enhanced by 20%. SIA enhances patient-specific Q-TWiST with substantial cost reduction, is minimally invasive and allows for a high patient turnover without compromising limb salvage. SIA has caused a Paradigm Shift in CLI Management.

East Orange and Newark, N.J. Purpose: Calf muscle pump dysfunction is a recognized factor in chronic venous insufficiency (CVI). We investigated the hypothesis that limbs with CVI have a reduced ankle range of motion (ROM) that may be responsible for the poor calf pump function associated with venous ulceration.

The aim was to assess 18 month outcomes of the paclitaxel eluting balloon (PEB) in patients with femoropopliteal (FP) in-stent restenosis (ISR). In a national prospective and multicentre cohort study, symptomatic patients with femoropopliteal in-stent restenosis were included from January 2012 to June 2013. Patients were treated by paclitaxel eluting balloon angioplasty (In Pact Admiral, Medtronic, Santa Rosa, CA, USA). Clinical and duplex scan follow-up evaluations were performed at 1, 3, 6, 9, 12, and 18 months. The primary endpoint was freedom from target lesion revascularisation (TLR) at 12 months. Secondary endpoints were major adverse cardiovascular events (MACE), Target extremity revascularisation (TER), primary and secondary sustained clinical improvement, recurrent restenosis rate, primary and secondary patency, quality of life assessed by EQ-5D questionnaire, technical success, clinical success, and length of stay RESULTS: A total of 53 patients were enrolled. After a blin...

structured around an original "case management" approach. Multiple chapters discuss assessment and management of psychosocial stressors. The last part is titled "Moving Cardiac Rehabilitation into the Next Century: Contemporary Challenges and Implementation Issues." It outlines a very broad approach to the delivery of appropriate rehabilitation care in the medical environment of the future. The authors discuss trends in areas such as home-based cardiac rehabilitation, patient self-learning, measuring patient outcomes, and program quality, and they review the effect of societal issues on patient management in the chapters on medicolegal and economic issues. The volume boasts an impressive list of contributors from many of the major cardiac centers in the country. Its readers will find that it offers a very practical and accessible format, a comprehensive review of the literature, and an extensive and well structured index. This book fills an important niche in the modern management of the patient with cardiovascular disease. This book may best be considered an excellent update on obesity that is somewhat analogous to, but more detailed than, what might be expected in a broad textbook discussion, with some emphasis on selected cardiovascular complications.

BACKGROUND: Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication. STUDY DESIGN: In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeonreviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed.

Diabetic foot infections are a common and often serious problem, accounting for a greater number of hospital bed days than any other complication of diabetes. Despite advances in both antibiotic therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a number of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific for infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific for these infections. The following year, the Infectious Diseases Society of America (IDSA) published their Diabetic Foot Infection Guidelines. In this article, we review some of the critical points from the Executive Summary of the IDSA document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since the publication of the original document in 2004. The importance of a multidisciplinary limb salvage team, apropos this special joint issue of the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated. ( J Vasc Surg 2010;52:67S-71S.)

Background: Renal artery stent placement is a recognized treatment for patients with hemodynamically significant renal artery stenosis when medical therapy fails. Duplex ultrasound (DUS) is the primary method used for noninvasive assessment of renal artery patency. Arterial stents alter the compliance of the artery, which could make the standard reference values, based on native renal artery velocities, inaccurate. This study attempted to determine DUS criteria for renal artery in-stent restenosis (ISR). Methods: We studied 67 consecutive patients with suspected renal artery ISR based on abnormal renal DUS results, defined as peak systolic velocity (PSV) >200 cm/s and renal/aortic velocity ratio (RAR) >3.5. The ISR patients were compared with 55 consecutive nonstented patients who underwent renal DUS evaluation and renal angiography. Those with >50% angiographic narrowing in each group were analyzed, and renal PSV and RAR were compared. Results: In the 67 patients with renal stents and 55 patients without renal stents, a statistically significant correlation was found for both PSV and RAR in detecting renal ISR and renal artery stenosis as defined by quantitative angiography (P ‫؍‬ .02). For any level of angiographic stenosis >50%, the ISR group had relatively higher PSV and RAR compared with the nonstented group. Receiver operating characteristic curves indicated that PSV >395 cm/s or RAR >5.1 were the most predictive of angiographically significant ISR >70%. Conclusion: The current DUS criteria for native renal arteries may overestimate the degree of angiographic ISR due to changes in compliance. We recommend that DUS laboratories make adjustments in PSV and RAR obtained by DUS when monitoring the patency of renal stents for ISR. ( J Vasc Surg 2009;50:119-23.)

We propose an anatomy-based approach for an efficient construction of a three-dimensional human normal cerebral arterial model from segmented and skeletonized angiographic data. The centerline-based model is used for an accurate angiographic data representation. A vascular tree is represented by tubular segments and bifurcations whose construction takes into account vascular anatomy. A bifurcation is defined quantitatively and the algorithm calculating it is given. The centerline is smoothed by means of a sliding average filter. As the vessel radius is sensitive to quality of data as well as accuracy of segmentation and skeletonization, radius outlier removal and radius regression algorithms are formulated and applied. In this way, the approach compensates for some inaccuracies introduced during segmentation and skeletonization. To create the frame of vasculature, we use two different topologies: tubular and B-subdivision based. We also propose a technique to prevent vessel twisting. The analysis of the vascular model is done on a variety of data containing 258 vascular segments and 131 bifurcations. Our approach gives acceptable results from anatomical, topological and geometrical standpoints as well as provides fast visualization and manipulation of the model. The approach is applicable for building a reference cerebrovascular atlas, developing applications for simulation and planning of interventional radiology procedures and vascular surgery, and in education.

In the Netherlands, vascular surgery is not a monospecialty. Vascular interventions are performed by general surgeons with an interest and additional training in vascular surgery. The Dutch Society for Vascular Surgery was founded in 1981, is stimulating and coordinating patient care and research and is also involved in postgraduate training of vascular surgery. An official 2-year training programme has been established in 1986. Currently, there are 12 vascular training programmes certified to certify surgeons as vascular surgeons. The quality of the training programmes is thoroughly evaluated every 5 years. Renewed certification is based on a written report from the director of the programme, supplemented with an 'on-site' visit and established by the Dutch Association of Surgeons of the Netherlands. Currently, (vascular) surgical training is being restructured due to working hour requirements (EC Directive), shortening of the years of training (currently 6+2) and further improvement of the quality of training. D 2004 Elsevier B.V. All rights reserved.

Background: The objective of this study was to evaluate the prevalence and profile of patients presenting with chronic venous insufficiency (class C3-C6) and cascading deep venous reflux involving femoral, popliteal, and crural veins to the ankle. Methods: From September 2001 to April 2004, 2894 patients were referred to our center for possible venous disorders. The superficial, deep, and perforator veins of both legs were investigated with color duplex scanning. The criterion for inclusion in this study was the existence of cascading deep venous reflux involving the femoral, popliteal, and crural veins to the ankle whose duration had to be longer than 1 second for the femoropopliteal vein and longer than 0.5 seconds for the crural vein. The advanced CEAP classification, the Venous Clinical Severity Score (VCSS), the Venous Segmental Disease Score (reflux; VSDS), and the Venous Disability Score (VDS) were used. Results: Seventy-one limbs in 60 patients were identified. Eleven limbs (15.5%) were classified as C3, 36 (50.7%) as C4, 21 (29.6%) as C5, and 3 (4.2%) as C6. A primary etiology was identified in 11 (15.5%) limbs, and a postthrombotic etiology was identified in 60 limbs (84.5%). In the latter group, all but four patients were aware that they had had a previous deep venous thrombosis. In addition to femoropopliteal and calf veins, reflux was present in the common femoral vein in 60 (84.5%), the deep femoral vein in 27 (38%), and the muscular calf veins in 62 (87.3%). Incompetent perforator veins were identified in 53 (74.6%) limbs. Fifty-one (71.8%) limbs had a combination of superficial venous insufficiency (AS 2 , AS 2,3 , AS 4 , or their combination) previously treated or present. Of these, 11 had primary etiology alone, and 40 had a secondary etiology with or without primary disease. Means and 95% confidence intervals of the VCSS, VSDS, and VDS were 9.72 , respectively. A significant increase in the VCSS and in the VSDS (P < .0001) paralleled the CEAP clinical class. The VDS was higher in the C3 and C6 classes but did not reach significance. There was a significant link between the pain magnitude in the VCSS and the VDS (P < .0001). Severity of pain and high VDS did not depend on the wearing of elastic compression stockings. VCSS increased significantly according to the presence of an incompetent perforator vein (P < .05) and/or reflux in the deep femoral vein (P < .05).

To determine the effect of elastic compression stockings on deep venous hemodynamics we measured ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, amplitude of venous pressure excursion, and duplex-derived common femoral and popliteal vein diameter and peak flow velocities with and without stockings in 10 healthy subjects and 16 patients with chronic deep venous insufficiency. The effects of below-knee and above-knee 30 to 40 torr and 40 to 50 torr gradient stockings were studied. Despite documentation of substantial stocking compressive effects by skin pressure measurements, neither below-knee or above-knee elastic compression stockings significantly improved ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, or the amplitude of venous pressure excursion in healthy patients or in patients with deep venous insufficiency (p > 0.05).

Objetivos: O objetivo deste estudo foi o de analisar morbidade e mortalidade pós-cirúrgicas em pacientes submetidos à cirurgia de aneurisma da aorta torácica e aneurisma toracoabdominal no Departamento de Cirurgia Vascular do IRCCS San Raffaele, Milão.

INTRODUCTION: Femoral wound complications can threaten vascular grafts. Muscle flaps can be used to facilitate soft-tissue coverage and graft salvage. We report a series of sartorius flaps performed by vascular surgeons in the treatment of complicated femoral wounds. METHODS: Rotational sartorius flaps were performed to attempt salvage of underlying vascular grafts. We reviewed a prospective database to determine the outcomes of sartorius flaps on facilitating wound healing and graft salvage and patency. RESULTS: From 2005 to 2008, 21 sartorius flaps were performed in infected or threatened femoral wounds. Original operations included femoral endarterectomy with patch repair in 8, aortofemoral graft in 6, axillofemoral graft in 4, and femoral-distal bypass in 3 patients. Complete wound healing occurred in 18 patients (86%). Primary wound closure was achieved in 7 patients. Secondary wound closure was achieved in 11 patients with mean healing time of 2.3 months. All vascular reconstructions remained patent at the 9.5-month follow-up. CONCLUSIONS: Sartorius muscle flaps are effective at facilitating complicated femoral wound healing while maintaining graft salvage and patency.

Objective: To produce a comprehensive anatomical and hemodynamic ultrasound scan mapping of the whole limb in patients with primary varicose veins (VVs). Design: An analysis of venous duplex scans performed on patients referred for treatment of primary VVs. Methods: A total of 2036 limbs were evaluated, looking for the origin of VVs in the saphenous systems and in the perforating vein (PV) systems, as well as for the presence of non-saphenous reflux. Results: The sapheno-femoral junction (SFJ) of the great saphenous vein (GSV) was involved in 1330 limbs (65.3%). We have noted that finding reflux in the groin does not imply that it originates at that point necessarily, as reflux from the pelvis or abdominal wall can also cause primary VVs (SFJ reflux, 41.9% and competent SFJ with reflux from proximal veins, 35.4%). We also noted that analyzing only the presence of reflux in the SFJ of the GSV would miss 10.9% of limbs of reflux in the SFJ of the anterior accessory GSV. In 237 limbs (11.6%), reflux was observed in the popliteal fossa. In the PV system, we distinguished those PVs with retrograde flow that acted as an origin of the VVs, and other PVs that acted as re-entry points. Based on this difference, the location identified as the most frequent origin of VVs in the PV system was the thigh, specifically in the group of PVs of the medial thigh of the femoral canal, with 85 PVs with a total of 238 incompetent PVs identified. Pure non-saphenous reflux was observed in 162 limbs (8%).

Background: To determine whether renal perfusion with cold crystalloid solution enriched with histidine-tryptophanketoglutarate (Custodiol; Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) provides better protection against renal ischemic injury than cold lactated Ringer's solution in patients undergoing thoracoabdominal aortic aneurysm open repair. Methods: We analyzed a prospectively compiled database containing all 111 consecutive patients who underwent thoracoabdominal aortic aneurysm open repair at our center from 2008 to 2011. A cohort of 104 consecutive patients was identified of which 50 (48%) had renal perfusion with Custodiol and 54 (52%) with lactated Ringer's solution. Propensity score matching based on baseline clinical variables, which were expected to influence renal outcomes, was performed to correct for any bias that may have been associated with the use of Custodiol. Acute kidney injury (AKI) as defined by Kidney Disease Improving Global Outcomes guidelines and perioperative estimated glomerular filtration rate were compared in the two groups. Independent predictors of AKI were also identified by multivariate analysis. Results: After propensity score matching, we were able to match 42 Custodiol cases one-to-one with those receiving perfusion with lactated Ringer's solution. Overall 30-day mortality was 5.9%; temporary hemodialysis or continuous veno-venous hemofiltration was needed in 4.8% of the patients without any case of dialysis at discharge. Freedom from AKI was significantly increased in the Custodiol group (38.1% vs 9.5%; P [ .002) despite longer total renal ischemic time (51.5 6 16.4 minutes vs 43.6 6 16.0 minutes; P [ .05). By analysis of variance for repeated measures, a significant upward trend of perioperative estimated glomerular filtration rate was observed in the Custodiol group (group 3 time interaction [ F 3,66 ; P < .001), and by multivariate analysis, Custodiol perfusion was the only independent predictor of non-AKI (P [ .04). Conclusions: The use of Custodiol was safe and provided improved perioperative renal function compared with lactated Ringer's solution. Randomized trials are needed to confirm these data and to assess their clinical consequences. (J Vasc Surg 2014;59:623-33.) From the Vascular Surgery a and Anesthesia and Intensive Care, b Università Vita-Salute, San Raffaele Scientific Institute.

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. ( J Vasc Surg 2010;52:825-33.)

Objective: Assessment of walking distance by treadmill testing is the most commonly used method to evaluate the effect of treatment in patients with peripheral arterial disease. However, treadmill testing is time consuming, relatively expensive, and does not adequately reflect real life functional ability. We hypothesized that the Walking Impairment Questionnaire (WIQ) could be an alternative tool to assess objective improvement in functional walking ability of patients with intermittent claudication. Methods: This was a validation study. It was conducted through the outpatient clinic for vascular surgery. Patients with intermittent claudication were referred for supervised exercise therapy. Treadmill testing (absolute claudication distance [ACD]), WIQ, and quality of life questionnaires (RAND-36 and EuroQol) were administered at study onset and after 3 months of supervised exercise therapy. Responsiveness was determined by mean changes in and correlation coefficients of WIQ, ACD, and quality of life questionnaires. Patients were categorized into quartiles based on the increase in ACD, which were subsequently related to change in WIQ and quality of life. Results: The mean pre-and post-treatment total WIQ scores of 91 patients were 0.45 (0.22) and 0.58 (0.22), respectively. The correlation coefficient between the change in total WIQ score and ACD was 0.331 (P ‫؍‬ .004). A 0.1 change in total WIQ score corresponded to a change of 345 meters in ACD. Analysis of the four quartiles compared to an increase in ACD showed that a greater increase in ACD corresponded with a greater increase in WIQ score, from 0.06 to 0.25 (P ‫؍‬ .011). Conclusion: These data indicate that the WIQ is a valid tool to detect improvement or deterioration in the daily walking ability of patients with intermittent claudication. Hence, the WIQ can be used as an alternative to treadmill testing for objective assessment of functional walking ability, both in daily practice and in clinical trials. ( J Vasc Surg 2009;50:89-94.)