OBJECTIVE:

To explore the associations between beta-blocker use and clinical outcomes (death, hospitalisation with myocardial infarction (MI) or stroke, major amputation and recurrent vascular surgery) after primary vascular reconstruction.

METHODS:

Patients who had primary vascular surgical or endovascular reconstruction due to symptomatic peripheral arterial disease, in Denmark between 1996 and 2007 were included. We obtained data on filled prescriptions, clinical outcomes and confounding factors from population-based healthcare registries. Beta-blocker users were matched to non-users by propensity score, and Cox-regression was performed. All medications were included as time-dependent variables.

RESULTS:

We studied 16,945 matched patients (7828 beta-blocker users and 9117 non-users) with a median follow-up period of 582 days (range, 30-4379 days). The cumulative risks were as follows: all-cause mortality, 17.9%; MI, 5.3%; stroke, 5.6%; major amputation, 9.1%; and recurrent vascular surgery, 23.1%. When comparing beta-blocker users with non-users: adjusted hazard ratio: MI, 1.52 (95% CI, 1.31-1.78); stroke, 1.21 (95% CI, 1.03-1.43); and major amputation, 0.80 (95% CI, 0.70-0.93).

CONCLUSION:

Beta-blocker use after primary vascular surgery was associated with a lower risk of major amputation but an increased risk of hospitalisation with MI and stroke. No associations were found between beta-blocker use and all-cause mortality or the risk of recurrent vascular surgery. However, our results are not sufficient to alter the indication for beta-blocker use among symptomatic peripheral arterial disease patients.

OBJECTIVE:

To evaluate the automated 2D-3D image overlay system ("3D Roadmap") for use during endovascular aneurysm repair (EVAR) in the hybrid operating theater.

METHODS:

Datasets of preoperative CT images were modified to subtract dense bone marrow to improve the visualization of vasculature on the overlaid image, and allow for accurate navigation of the endovascular devices. The 3D-CT overlay image was registered on the 2D fluoroscopy image to mark the iliac crest and lumbar vertebrae on both images as landmarks.

RESULTS:

Arteriography was performed only twice to confirm the precision of the position of renal artery and the final evaluation. Twenty patients underwent EVAR with Medtronic Endurant, Gore Excluder, or COOK Zenith using "3D Roadmap". The origin of the renal artery and iliac bifurcation were registered with complete accuracy in 10 patients (50%). The lower renal artery deviated toward the cranial side less than 3 mm in six patients. In all cases, EVAR was successful, and completed with the volume of contrast material limited to 43.8 ± 3.1 mL.

CONCLUSION:

"3D Roadmap" was confirmed to be valuable for visualization of vessel origin in a fused image and for reduction of contrast material during EVAR.

OBJECTIVES:

To review our experience with fenestrated endovascular aneurysm repair (F-EVAR) to treat complications after previous standard infrarenal endovascular aneurysm repair (EVAR).

METHODS:

A prospectively maintained database including all consecutive patients with juxtarenal abdominal aortic aneurysm that were treated with F-EVAR after failed previous EVAR within the period March 2002 to November 2012 at the University Medical Center of Groningen, Netherlands (up to October 2009), and the Klinikum Nürnberg Süd, Germany (from November 2009) was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity, and late procedure-related events with regard to survival, target vessel patency, endoleak, renal function, and reintervention.

RESULTS:

A total of 26 patients (24 male, mean age 73.2 ± 6.5 years) were treated. All patients had proximal anatomies precluding endovascular reintervention with standard techniques. In 23 patients a fenestrated proximal cuff was used, and in three patients a bifurcated fenestrated stent graft. Technical success was achieved in 24 (92.3%) patients. One patient required on-table open conversion because of impossibility to retrieve the top cap as a result of twist of the ipsilateral limb. In the second patient the right kidney was lost due to inadvertent stenting in a smaller branch of the renal artery. Catheterization difficulties, all related to the passage through the limbs or struts of the previous stent graft, were encountered in 11 (42.3%) cases, including five (19.2%) patients with iliac access problems and six (23.1%) with challenging renal catheterization. Operative target vessel perfusion success rate was 94.6% (70/74). Operative mortality was 0%. Mean follow-up was 26.8 ± 28.5 months. No proximal type I endoleak was present on first postoperative CTA. The mean aneurysm maximal diameter decreased from 73 ± 20 mm to 66.7 ± 21 mm (p < .05). There were six late deaths, one of them aneurysm related. Estimated survival rates at 1 and 2 years were 94.1 ± 5.7% and 87.4 ± 8.4%, respectively. Patency during follow-up for the target vessels treated successfully with a fenestrated stent graft was 100% (70/70). Reintervention was required in four cases, including one acute conversion due to rupture, one for iliac limb occlusion and two for type Ib and II endoleak. Renal function deterioration was observed solely in the two cases of primary technical failure.

CONCLUSIONS:

F-EVAR represents a feasible option for the repair of juxtarenal abdominal aortic aneurysm after prior EVAR failure. It is advantageous in terms of mortality and less morbid than open surgery, but is associated with increased technical challenges because of the previously placed stent graft. Outcome seems related to initial technical success.

OBJECTIVE

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BACKGROUND:

There is limited information regarding outcome in patients not available for revascularisation. Our aim was to identify factors related to ulcer healing in diabetic patients with severe peripheral arterial disease who were not available for revascularisation.

METHODS:

Diabetic patients with a foot ulcer, consecutively presenting at a multidisciplinary foot centre with systolic toe pressure <45 mmHg or an ankle pressure <80 mmHg were prospectively included. Patients who received revascularisation were excluded. All patients had continuous follow-up until healing or death.

RESULTS:

Out of 602 patients (median age: 76 years) included in this study, 50% healed either primarily (76%) or with a minor amputation (24%). Seventeen percent of patients healed after major amputation and 33% died unhealed. By regression analysis, rest pain, impaired renal function, ischemic heart disease, cerebral vascular disease, extent of tissue destruction, and ankle pressure >50 mmHg affected the outcome of the ulcers.

CONCLUSION:

Diabetic patients with ischemic foot ulcers not available for revascularisations are not excluded from healing without major amputation. Factors strongly related to outcome were co-morbidity, severity of peripheral arterial disease, and extent of tissue destruction. Our findings reinforce the need for a classification system considering these factors at decision-making for vascular intervention.