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Eur J Vasc Endovasc Surg [journal]
- Why Do Health Systems Not Fund Supervised Exercise Programmes for Intermittent Claudication? [EDITORIAL]
- Eur J Vasc Endovasc Surg 2014 Aug 28.
- Outcomes of Fenestrated/Branched Endografting in Post-dissection Thoracoabdominal Aortic Aneurysms. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Aug 28.
Fenestrated/branched thoracic endovascular repair (F/Br-TEVAR) is increasingly applied for atherosclerotic thoracoabdominal aortic aneurysm (TAAA); however, use in post-dissection TAAAs is still very limited. Experience with F/Br-TEVAR in the treatment of post-dissection TAAA is presented.Data were analysed from prospectively maintained databases including all patients with post-dissection TAAAs that underwent F/Br-TEVAR within the period January 2010 to July 2013 in two vascular institutions. Evaluated outcomes included initial technical success, operative mortality and morbidity, late survival, endoleak, aneurysm diameter regression, renal function, and reintervention during follow-up (FU).A total of 31 patients (25 male, mean age 65 ± 11.4 years) were treated. Technical success was 93.5% and 30-day mortality 9.6%. Temporary spinal cord ischaemia occurred in four (12.6%) patients, with no case of permanent paraplegia. Mean FU was 17.0 ± 10 months. There were seven late deaths, all aneurysm unrelated. Estimated overall survival rates were 83.9 ± 6.7, 76.4 ± 7.9 and 71.6 ± 8.7% at 6, 12, and 18 months, respectively. Impairment of renal function occurred in two (6.4%) patients. Endoleaks were diagnosed in 12 patients during FU, including six type IB endoleaks and six type II endoleaks. Reintervention was required in seven (22.5%) patients. Mean aneurysm sac regression was 9.3 ± 8.7 mm, with a false lumen thrombosis rate of 66.7% and 88.2% for patients with a FU longer than 6 and 12 months respectively.F/Br-EVAR is feasible for patients with a post-dissection TAAA. Although associated with additional technical challenges, and a significant need for reintervention, it leads to favourable aneurysm morphologic changes, and may play a more prominent role in the future for this type of pathology if long-term results confirm the good initial outcome.
- A Modified Approach of Proximalization of Arterial Inflow Technique for Hand Ischemia in Patients with Matured Basilic and Cephalic Veins. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Aug 22.
Proximalization of arteriovenous inflow (PAI) is an established technique for treating patients with access-induced hand ischemia. However, a prosthetic graft, used as arterial inflow, could minimize the benefits of a purely native fistula. In this study, a new PAI technique is reported, which avoids the use of prosthetic grafts in patients with matured basilic and cephalic veins.Eight patients (seven men, one woman; mean age 62 (45-82) years old) with grade III/IV critical dialysis access-related ischemia (DARI) and with a pre-existing Gracz fistula underwent an operation using modified PAI. The basilic and cephalic veins were preoperatively matured. During the operation, the former arteriovenous anastomosis was closed and the basilic vein was used as arterial inflow.All procedures were technically successful. All patients but one could be discharged with a warm, neurologically improved extremity with a significant reduction in pain. After a mean follow-up of 43.5 (0-52) months, there were no recurrent steal symptoms and all necrotic hand lesions healed. Two patients died during the follow-up, but with well-functioning fistulae. One fistula failed during follow-up and one further fistula was ligated because of chronic neurological damage, which was not improved after the PAI procedure. Four AVFs are still available for hemodialysis.The modification of the PAI technique with a basilic vein as presented here showed similar results to the original PAI procedure. This new procedure does not require prosthetic grafts as in the original PAI technique or a central venous catheter and leads to the enlargement of the puncture site as a result of the superficialization of the basilic vein. Therefore, it is believed that this new technique could be a good option for those patients with matured cephalic and basilic veins who suffer from severe access-related ischemia.
- Treatment of Symptomatic Aberrant Subclavian Arteries. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Aug 20.
The aim of this study is to present experience with 10 patients with symptomatic aberrant subclavian artery (ASA) and aneurysm of ASA who underwent surgical treatment.From 2008 to 2011 10 patients with symptomatic aberrant subclavian artery (mean age 60 years [range 24-90 years]) were studied. Symptoms were dysphagia (n = 7), dyspnea (n = 4), acute chest pain (n = 1), respiratory distress syndrome (n = 1), superior cava syndrome, and shock (n = 1). Six patients had aneurysm formation of the ASA (mean diameter of 7.1 cm [range 3.0-12.4 cm]; rupture [n = 1], dissection [n = 1]). All data were analyzed retrospectively.Treatment was performed as a hybrid procedure in eight patients. This included thoracic endoluminal graft exclusion with revascularization of the ASA, a pure endovascular procedure with two occluders in one patient, and an open procedure in one patient with ligation of the aberrant artery through a thoracotomy. Three patients died during the early postoperative period owing to pulmonary complications. All three suffered from a symptomatic aneurysm, and two were treated as an emergency procedure. Median follow-up was 20 months (range 12-49 months).A symptomatic ASA and its associated aneurysmal formation should be excluded after diagnosis. In most cases, a hybrid procedure consisting of thoracic endografting and revascularization of the ASA is feasible.
- Characterization of a Bioprosthetic Bicuspid Venous Valve Hemodynamics: Implications for Mechanism of Valve Dynamics. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Aug 20.
Chronic venous insufficiency (CVI) of the lower extremities is a common clinical problem. Although bioprosthetic valves have been proposed to treat severe reflux, clinical success has been limited due to thrombosis and neointima overgrowth of the leaflets that is, in part, related to the hemodynamics of the valve. A bioprosthetic valve that mimics native valve hemodynamics is essential.A computational model of the prosthetic valve based on realistic geometry and mechanical properties was developed to simulate the interaction of valve structure (fluid-structure interaction, FSI) with the surrounding flow. The simulation results were validated by experiments of a bioprosthetic bicuspid venous valve using particle image velocimetry (PIV) with high spatial and temporal resolution in a pulse duplicator (PD).Flow velocity fields surrounding the valve leaflets were calculated from PIV measurements and comparisons to the FSI simulation results were made. Both the spatial and temporal results of the simulations and experiments were in agreement. The FSI prediction of the transition point from equilibrium phase to valve-closing phase had a 7% delay compared to the PD measurements, while the PIV measurements matched the PD exactly. FSI predictions of reversed flow were within 10% compared to PD measurements. Stagnation or stasis regions were observed in both simulations and experiments. The pressure differential across the valve and associated forces on the leaflets from simulations showed the valve mechanism to be pressure driven.The flow velocity simulations were highly consistent with the experimental results. The FSI simulation and force analysis showed that the valve closure mechanism is pressure driven under the test conditions. FSI simulation and PIV measurements demonstrated that the flow behind the leaflet was mostly stagnant and a potential source for thrombosis. The validated FSI simulations should enable future valve design optimizations that are needed for improved clinical outcome.
- New Oral Anticoagulants in the Management of Venous Thromboembolism: A Major Advance? [EDITORIAL]
- Eur J Vasc Endovasc Surg 2014 Aug 21.
- The Influence of the CIVIQ Dimensions on Quality of Life of Patients with Primary Superficial Venous Incompetence. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Aug 20.
To get to know the influence of the four domains of the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ) on the quality of life (QoL) of patients with primary superficial venous incompetence, and their behaviour in relation to age, gender, occupation, body mass index (BMI), and also with respect to the clinical and anatomical classes of the CEAP.The sample was composed of 468 patients with primary superficial venous reflux (135 male and 333 female) who answered 100% of the questions in the Short Form-12 (SF12) and CIVIQ questionnaires. After a clinical and duplex examination, the patients were categorized as C0-6, Ep, As, Ap or As,p and Pr according to the CEAP classification. The relationships between CIVIQ domains and gender, age, occupation, BMI, and the clinical and anatomical classes of the CEAP classification were analyzed.Men reported better QoL than women (33.2 vs. 46.3) and this was also true for each of the CIVIQ's domains (p < .00). Pain (50.6) and physical restriction (45.3) were the dimensions with a greater influence on QoL, whereas social (41.7) and psychological (38.1) dimensions had a lesser influence. Patients aged between 45 and 64, household activities, and patients with C2-3 clinical classes were the patient groups with the worst scores in all the CIVIQ dimensions and those where significant differences were found. The BMI and anatomical distribution of the reflux had no influence on the QoL.Pain and physical restriction were the CIVIQ domains with greater influence on the QoL of patients with primary superficial venous reflux. Age increase (up to 64 years), female gender, household activities, and C2-3 CEAP clinical class were the main factors associated with the worst QoL perception.
- Continuous Regional Anaesthesia Provides Effective Pain Management and Reduces Opioid Requirement Following Major Lower Limb Amputation. [JOURNAL ARTICLE]
- Eur J Vasc Endovasc Surg 2014 Aug 16.
Postoperative stump pain after major lower limb amputation is a significant impediment to the recovery of amputees. The vast majority of patients require opioid analgesics following surgery, which are associated with opioid-related side-effects. Here, we investigate whether intraoperative placement of a peripheral nerve stump catheter followed by continuous infusion of local anesthetic is as effective at pain control as current analgesic practices. If beneficial, this procedure could potentially reduce post-amputation opioid consumption and opioid-related adverse effects.A retrospective chart review was conducted of 198 patients over a 4-year period who had undergone a major lower limb amputation for indications related to peripheral vascular disease. Postoperatively, 102 patients received a perineural catheter were compared to 96 patients who did not. The primary outcomes of this study were the amount of morphine equivalents used in the first 72 hours postoperatively and postoperative pain intensity in the first 24 hours.A total of 198 lower-limb amputations were selected for analyses. Multiple regression analyses indicated that perineural catheter use was associated with a lower cumulative postoperative opioid consumption over the first 72 hours but not postoperative pain scores at 24 hours. Perineural catheter use led to a 40% reduction in opioid use during the first 72 hours postoperatively. Mixed model repeated measures analysis demonstrated that this opioid reduction was consistent over time. Other variables related to total opioid use included age, pre-surgical chronic pain, pre-surgical opioid use, patient-controlled analgesia.Continuous perineural infusions of local anesthetic are a safe and effective method for reducing post-amputation opioid analgesic medications after major lower limp amputation.
- Part Two: Against the Motion. Venous Perforator Surgery is Unproven and Does not Reduce Recurrences. [Journal Article]
- Eur J Vasc Endovasc Surg 2014 Sep; 48(3):242-6.