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Eur J Vasc Endovasc Surg [journal]
- Reinforced Aneurysmorrhaphy for True Aneurysmal Haemodialysis Vascular Access. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Jan 21.
In 2008, a new technique of reinforced aneurysmorrhaphy with a polyester mesh tube for salvaging true aneurysmal arteriovenous (AV) haemodialysis access was described by us. In this study, the long-term patency and complication rates associated with this procedure were analysed, and the effect of reinforced aneurysmorrhaphy on high-flow vascular access was assessed.This was a retrospective non-randomised study with prospectively collected data performed at a single centre. Patients with true aneurysmal haemodialysis AV access who underwent aneurysmorrhaphy with external mesh prosthesis between March 2007 and October 2012 were included. Clinical assessment and duplex ultrasound were performed preoperatively, 1, 3, and 12 months postoperatively, and annually thereafter.Data from 62 patients (median age 60 years, range 28-81 years; 63% men) were analysed. The commonest indication was high-flow vascular access associated with the risk of high output cardiac failure (24 patients, 39%). The mean follow-up time was 14.66 ± 12.80 months. Primary patency rates at 6 and 12 months were 86% and 79% respectively. Assisted primary patency rates at 6 and 12 months were 89% and 80% respectively. In 23 patients (96%) operated on for high-flow vascular access, decreased vascular access flow was observed after the procedure. The average flow reduction after aneurysmorrhaphy was 2,197 mL/minute. Postoperative bleeding and infection necessitating surgical revision occurred in three (4.8%) and three (4.8%) patients respectively.Reinforced aneurysmorrhaphy with an external mesh prosthesis is an effective method for treating true aneurysmal haemodialysis AV access, with excellent long-term patency and minimal complications due to infection.
- Abdominal Hypertension and Decompression: The Effect on Peritoneal Metabolism in an Experimental Porcine Study. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Feb 13.
The aim of this study was to investigate the abdominal metabolic response and circulatory changes after decompression of intra-abdominal hypertension in a porcine model.This was an experimental study with controls. Three-month-old domestic pigs of both sexes were anesthetized and ventilated. Nine animals had a pneumoperitoneum-induced IAH of 30 mmHg for 6 hours. Twelve animals had the same IAH for 4 hours followed by decompression, and were monitored for another 2 hours. Hemodynamics, including laser Doppler-measured mucosal blood flow, urine output, and arterial blood samples were analyzed every hour along with glucose, glycerol, lactate and pyruvate concentrations, and lactate-pyruvate (l/p) ratio, measured by microdialysis.Laser Doppler-measured mucosal blood flow and urine output decreased with the induction of IAH and showed a statistically significant resolution after decompression. Both groups developed distinct metabolic changes intraperitoneally on induction of IAH, including an increased l/p ratio, as signs of organ hypoperfusion. In the decompression group the intraperitoneal l/p ratio normalized during the second decompression hour, indicating partially restored perfusion.Decompression after 4 hours of IAH results in an improved intestinal blood flow and a normalized intraperitoneal l/p ratio.
- Improvement of Venous Pumping Function by Double Progressive Compression Stockings: Higher Pressure Over the Calf is More Important Than a Graduated Pressure Profile. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Feb 10.
Previous studies have shown that so-called progressive elastic compression stockings (PECS) with a negative pressure gradient have a more pronounced effect on venous pump function than conventional, graduated stockings. The aim of this study was to investigate the effect of higher graduated and non-graduated pressures on the venous calf pump in patients with venous disease.The ejection fraction (EF) of the calf pump was measured by plethysmography under a standardized walking test in 20 patients suffering from chronic venous disease (CEAP C2-C5) without compression, (a) with one and (b) two PECS on top of each other, and (c) with one additional conventional stocking covering only the gaiter area to achieve a graduated high pressure profile. Interface pressure was measured in the gaiter area and on the calf.A significant improvement of EF compared with baseline was found with all three compression modalities. The two superimposed PECS, providing median pressures of 33 mmHg in the gaiter area and 46 mmHg at calf level, increased EF significantly up into the normal range. Increasing the gaiter pressure to 56 mmHg without changing the calf pressure did not result in further improvement.Two PECS applied on top of each other lead to a maximal improvement of the venous pump function, which cannot be further improved by increasing the pressure in the gaiter area thereby restoring a graduated pressure profile.
- Do Kidneys Need Blood? [EDITORIAL]
- Eur J Vasc Endovasc Surg 2014 Feb 10.
- The Chronic Cerebrospinal Venous Insufficiency Debate. [EDITORIAL]
- Eur J Vasc Endovasc Surg 2014 Feb 10.
- The Impact of Surgical Wound Bacterial Colonization on the Incidence of Surgical Site Infection After Lower Limb Vascular Surgery: A Prospective Observational Study. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Feb 7.
To study the relationship between surgical wound bacterial colonization and the development of surgical site infection (SSI) after lower limb vascular surgery. SSI is a major problem after lower limb vascular surgery. Most SSIs in vascular surgery are caused by Staphylococcal species that are part of normal skin flora. A prospective observational investigator blind study to examine quantitative and qualitative analysis of surgical wound bacterial colonization and the correlation with the development of SSI has been conducted.The study cohort comprised 94 consecutive patients with 100 surgical procedures. Swabs for microbiological analyses were taken from surgical wounds at four different time intervals: before surgery, just before the surgical area had been scrubbed, at the end of surgery, and on the first and second postoperative days. Postoperative complications were recorded.Three hundred and eighty-seven skin bacterial samples from 100 surgical wounds were analyzed. The most common bacteria isolated were coagulase-negative staphylococci (80%), Corynebacterium species (25%), and Propionibacterium species (15%). In 13 (62%) cases, the same bacterial isolates were found in the perioperative study samples as in the infected wounds. The incidence of SSI was 21%. Multivariate analysis revealed that high bacterial load on the second postoperative day and diabetes independently increased the risk of SSI. Elective redo surgery was protective against the development of SSI.A high bacterial load in the postoperative surgical wound independently increases the risk of the development of SSI after lower limb vascular surgery.
- A Shaggy Aorta is Associated with Mesenteric Embolisation in Patients Undergoing Fenestrated Endografts to Treat Paravisceral Aortic Aneurysms. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Feb 3.
Bowel ischaemia is a life-threatening complication of endovascular aneurysm repair. This study aims to evaluate the factors associated with mesenteric ischaemia in patients undergoing fenestrated aortic endografts to treat paravisceral aneurysms.Consecutive patients undergoing double or triple fenestrated stent graft insertion were retrospectively analysed. No patients were declined surgery based on anatomic complexity. Preoperative demographics, procedure-related variables, and anatomical factors were examined. Using 3D software, the aortic thrombus volume from the coeliac axis to the lowest renal, aortoiliac tortuosity, and aortic irregularity index (as graded by 3 independent assessors, graded 0-3 based on severity) were compared. Univariate analysis was performed to identify risk factors for the development of bowel ischaemia.Ninety-nine patients underwent elective aneurysm repair (64 triple fenestrations and 35 double fenestrations), 5% of which developed bowel ischaemia, and of these 80% (4/5) died. Mesenteric ischaemia was significantly associated with increased aortic irregularity (median [range], 2 [1-3] vs. 1 [0-2], p = .005, ischaemia vs. no ischaemia) and increased thrombus volume (37 ± 8 vs. 21 ± 12, p = .007) but not aortoiliac tortuosity (1.4 [1.2-1.5] vs. 1.30 [1.2-1.7], p = .3), inferior mesenteric or internal iliac artery patency. Mesenteric ischaemia was also associated with a significantly higher preoperative creatinine (mean ± SD: 183 ± 74 vs. 111 ± 43, p = .007).The presence of aortic irregularity and increased thrombus volume in the paravisceral segment predicts the occurrence of mesenteric and renal ischaemia in patients treated with fenestrated endografts. This is likely to be related to graft manipulation and catheterisation of visceral vessels.
- Ultrasound Measurement for Abdominal Aortic Aneurysm Screening: A Direct Comparison of the Three Leading Methods. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Jan 31.
Ultrasound (US) is non-invasive and cost-effective for screening abdominal aortic aneurysms (AAAs) but there is no universally accepted method to measure the aortic diameter. This study evaluates the accuracy, reproducibility, and repeatability of three methods: inner-to-inner (ITI), leading-to-leading edge (LTL), and outer-to-outer (OTO). The secondary objective of this study was to determine whether aneurysm size or grade of operator had any effect on either intra- or inter-observer variability.Fifty static US images were measured by six assessors (2 vascular radiologists, 2 interventional radiology trainees, and 2 sonographers) on two separate occasions 6 weeks apart. Repeatability and reproducibility were calculated and compared with computed tomography (CT) as the gold standard.All three methods have high repeatability and reproducibility when static images are used. The inter-observer reproducibility coefficients between assessors were 0.48 cm, 0.35 cm, and 0.34 cm for ITI, LTL and OTO, respectively. The intra-observer repeatability coefficients between assessors were 0.30 cm, 0.20 cm, and 0.19 cm for ITI, LTL and OTO, respectively. The mean difference between CT and OTO, LTL, and ITI was 1 mm, 3 mm, and 5 mm, respectively (all underestimations) (p < .0001).US consistently underestimates aortic size when compared with CT, with ITI demonstrating the greatest underestimation (on average 5 mm). In the UK, this underestimation by the NHS Abdominal Aortic Aneurysm screening programme reduces the sensitivity of the screening test and may impact on the way in which vascular specialists interpret the findings of the screening programme.
- Angiosome-targeted Lower Limb Revascularization for Ischemic Foot Wounds: Systematic Review and Meta-analysis. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Jan 31.
The efficacy of angiosome-targeted revascularization to achieve healing of ischemic tissue lesions of the foot and limb salvage is controversial. This issue has been investigated in this meta-analysis.A systematic review of the literature and meta-analysis of data on angiosome-targeted lower limb revascularization for ischemic tissue lesions of the foot were performed.Nine studies reported on data of interest. No randomized controlled study was available. There were 715 legs treated by direct revascularization according to the angiosome principle and 575 legs treated by indirect revascularization. The prevalence of diabetes was >70% in each study group and three studies included only patients with diabetes. The risk of unhealed wound was significantly lower after direct revascularization (HR 0.64, 95% CI: 0.52-0.8, I(2) 0%, four studies included) compared with indirect revascularization. Direct revascularization was also associated with significantly lower risk of major amputation (HR 0.44, 95% CI: 0.26-0.75, I(2) 62%, eight studies included). Pooled limb salvage rates after direct and indirect revascularization were at 1 year 86.2% vs. 77.8% and at 2 years 84.9% vs. 70.1%, respectively. The analysis of three studies reporting only on patients with diabetes confirmed the benefit of direct revascularization in terms of limb salvage (HR 0.48, 95% CI: 0.31-0.75, I(2) 0%).The results of the present meta-analysis suggest that, when feasible, direct revascularization of the foot angiosome affected by ischemic tissue lesions may improve wound healing and limb salvage rates compared with indirect revascularization. Further studies of better quality and adjusted for differences between the study groups are needed to confirm the present findings.