Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Continuing expansion of internal iliac artery aneurysms after surgical exclusion of the inflow. A report of two cases

Two patients with continuing expansion of an internal iliac artery aneurysm following earlier repair of an aortoiliac aneurysm are described. At the primary operation, inflow to small internal iliac aneurysms had been interrupted by simple proximal ligation only. During follow-up, however, increasing diameter of the by CT-angiography completely thrombosed internal iliac aneurysms required re-operation. The observation of continuing growth of thrombosed internal iliac artery aneurysms following proximal ligation emphasises the danger of persistent collateral circulation and supports the concept of endotension in the absence of endoleak following endovascular AAA repair.

Decreased smooth muscle cell/extracellular matrix ratio of media of femoral artery in patients with atherosclerosis and hyperhomocysteinemia

The aim of this study was to determine whether the morphology of the muscular femoral artery in patients with atherosclerosis and hyperhomocysteinemia differs from that of atherosclerotic vessels from patients with normal homocysteine levels. Whole-vessel biopsies of the superficial femoral artery were taken from patients with symptomatic atherosclerotic disease with and without hyperhomocysteinemia and from patients without atherosclerosis from traumatic amputations. The morphology of these specimens was studied qualitatively by light and electron microscopy and quantitatively by light microscopy in combination with a video overlay system. Atherosclerotic lesions in patients with hyperhomocysteinemia were morphologically similar to those in patients with normal homocysteine levels, except for a significantly decreased smooth muscle cell/extracellular matrix ratio of the media in hyperhomocysteinemic patients (P=0.02 versus normohomocysteinemic atherosclerotic group and P=0.001 versus group without a history of cardiovascular disease). Hyperhomocysteinemia is associated with a significant decrease of the smooth muscle cell/extracellular matrix ratio of the media of muscular femoral arteries without significant changes in medial thickness. Further investigations should concentrate on the cause of this newly discovered phenomenon and its impact on vascular compliance.

Is semi-closed endarterectomy of the superficial femoral artery combined with a short venous bypass in case of insufficient venous material an acceptable alternative for limb-threatening ischemia?

BACKGROUND

The aim of this study was to analyse the results of infragenual arterial revascularisation using semiclosed endarterectomy of the superficial femoral artery combined with a short venous bypass in patients with critical leg ischemia and insufficient venous material for a straightforward femorocrural reconstruction.

METHODS

From December 1990 through December 1998 thirty patients were studied (22 males and 8 females; mean age 65 years, range 31-92 years). The mean follow-up was 26 months (range 1-96 months). Cumulative primary patency and limb salvage rates were calculated according to life-table analysis.

RESULTS

The cumulative primary patency was 60.3% at 1 year and 48.4% at 3 years. The limb salvage rate was 68.6% at 1 and at 3 years.

CONCLUSIONS

In patients with limb-threatening ischemia and lack of venous material for a straightforward venous femorocrural bypass, semi-closed endarterectomy of the superficial femoral artery combined with a short popliteo-crural bypass provides a good alternative.

Percutaneous duplex-guided thrombin injection for treatment of iatrogenic femoral artery pseudoaneurysms

OBJECTIVES

to evaluate the feasibility of treatment of post-catheterisation pseudoaneurysms with duplex-guided thrombin injection.

TECHNIQUE

the technique of duplex-guided injection of thrombin in post-catheterisation pseudoaneurysms of the femoral artery is described and illustrated.

RESULTS

between December 1998 and October 1999, eight post-catheterisation pseudoaneurysms of the femoral artery were successfully thrombosed with thrombin injection. One patient developed a new pseudoaneurysm within 6 hours and this was also successfully treated with thrombin. Follow-up duplex-scanning at 3 months revealed no recurrences. No other adverse events occurred.

CONCLUSIONS

this initial experience suggests that duplex-guided thrombin injection in the treatment of post-catheterisation pseudo-aneurysms is feasible and safe.

Normohomocysteinaemia and vitamin-treated hyperhomocysteinaemia are associated with similar risks of cardiovascular events in patients with premature atherothrombotic cerebrovascular disease. A prospective cohort study

BACKGROUND

Mild hyperhomocysteinaemia (HHC) is associated with an increased risk of premature atherothrombotic cerebrovascular disease. We investigated the clinical efficacy with regard to the incidence of cardiovascular events of treatment of mild HHC with vitamin B(6) plus folic acid.

METHODS

We studied 224 consecutive patients with clinically manifest atherothrombotic cerebrovascular disease with onset before the age of 56. Follow-up was obtained in 203 (90.6%) patients. At baseline, 52 (25.6%) were hyperhomocysteinaemic after methionine loading and started treatment with vitamin B(6) (250 mg) plus folic acid (5 mg); 151 (74.4%) were normohomocysteinaemic (reference group).

RESULTS

During follow-up (median 57 months), 31 (20.5%) of the normo- and 11 (21.2%) of the hyperhomocysteinaemic patients had a new cardiovascular event. The crude incidence rate per person-year for any cardiovascular event was similar in both groups (0.043 [CI, 0.029-0.057] in the normo- vs. 0.045 [CI, 0.021-0. 069] in the hyperhomocysteinaemic group). Multivariate Cox-regression analyses showed that hypertension and cholesterol levels were associated with an increased risk of new cardiovascular events in the total group [relative risk [RR] (yes vs. no), 7.4 (3. 4-16.0) and RR (per 1 mmol/l), 1.9 (CI, 1.4-2.7)]. The adjusted RR for new cardiovascular events in the hyper- as compared to the normohomocysteinaemic patients was 0.96 (CI, 0.48-1.92).

CONCLUSION

These data are consistent with a protective effect of treatment with vitamin B(6) plus folic acid in patients with premature atherothrombotic cerebrovascular disease and post-methionine HHC.

[Radiation-induced arterial disease]

Arterial occlusive disease developed after radiation therapy in three patients: a woman aged 56 had a sensation of heaviness in her right arm and bluish-black discolorations of fingers 3 years after radiation therapy for breast carcinoma, and two men aged 46 and 45 years had intermittent claudication 23 and 14 years, respectively, after radiation therapy for testicle malignancy. After creation of a bypass, the symptoms subsided. Radiation-induced arterial disease is a rare complication after radiotherapy and usually presents after a latent period of several years. Arterial lesions induced by radiotherapy may be distinguished from atherosclerotic lesions by their atypical localization, limited to the irradiated sites, and occurrence at an earlier age. Symptoms may be masked by pain, limitation of motion, nerve root damage and lymphoedema and may therefore not always be recognized. Indications for treatment are identical to those for atherosclerotic occlusive disease, but due to increased risk of restenosis, rethrombosis and graft infection, percutaneous transluminal angioplasty (with or without stent), endarterectomy or venous bypass surgery should be preferred to prosthetic bypass material.

Effect of homocysteine-lowering treatment with folic acid plus vitamin B6 on progression of subclinical atherosclerosis: a randomised, placebo-controlled trial

BACKGROUND

A high plasma homocysteine concentration is associated with increased risk of atherothrombotic disease. We investigated the effects of homocysteine-lowering treatment (folic acid plus vitamin B6) on markers of subclinical atherosclerosis among healthy siblings of patients with premature atherothrombotic disease.

METHODS

We did a randomised, placebo-controlled trial among 158 healthy siblings of 167 patients with premature atherothrombotic disease. 80 were assigned placebo and 78 were assigned 5 mg folic acid and 250 mg vitamin B6 daily for 2 years. The primary endpoint was the development or progression of subclinical atherosclerosis as estimated from exercise electrocardiography, the ankle-brachial pressure index, and carotid and femoral ultrasonography.

FINDINGS

Ten participants in the treatment group, and 14 in the placebo group dropped out. Vitamin treatment, compared with placebo, was associated with a decrease in fasting homocysteine concentration (from 14.7 to 7.4 micromol/L vs from 14.7 to 12.0 micromol/L), and in postmethionine homocysteine concentration (from 64.9 to 34.9 micromol/L vs from 64.8 to 50.3 micromol/L). It was also associated with a decreased rate of abnormal exercise electrocardiography tests (odds ratio 0.40 [0.17-0.93]; p=0.035). There was no apparent effect of vitamin treatment on ankle-brachial pressure indices (0.87 [0.56-1.33]), or on carotid and peripheral-arterial outcome variables (1.02 [0.26-4.05] and 0.86 [0.47-1.59], respectively).

INTERPRETATION

Homocysteine-lowering treatment with folic acid plus vitamin B6 in healthy siblings of patients with premature atherothrombotic disease is associated with a decreased occurrence of abnormal exercise electrocardiography tests, which is consistent with a decreased risk of atherosclerotic coronary events.

Is organ ischaemia a determinant of the outcome of operations for suprarenal aortic aneurysms?

OBJECTIVE

To find out if morbidity and mortality after thoracoabdominal approaches for suprarenal aortic aneurysms are related to the duration of organ ischaemia.

DESIGN

Retrospective study.

SETTING

University hospital, The Netherlands.

SUBJECTS

72 operations for suprarenal aortic aneurysms.

MAIN OUTCOME MEASURES

Duration of organ ischaemia, morbidity and mortality.

RESULTS

There were 72 patients with 3 group A (Crawford type III), 10 group B (Crawford type IV), 37 group C (supracoeliac), and 22 group D (suprarenal) aneurysms. Median duration of ischaemia was 57 minutes for both the spinal cord and the mesenteric arteries, and 59 and 63 minutes for the right and left renal arteries, respectively. There were 52 major complications in 33 patients. Mesenteric ischaemia of longer than 60 minutes was associated with a significant higher complication rate (21/32, 66% compared with 13/40, 33%, p = 0.01). Spinal cord ischaemia of longer than 60 minutes was not associated with a significantly increased incidence of paraplegia (2/40 compared with 6/32, p = 0.13).

CONCLUSIONS

We conclude that with surgery for suprarenal aneurysms a significant higher complication rate is noted with increased duration of mesenteric ischaemia.

Reconstruction of the supra-aortic trunks

OBJECTIVE

To review our 10-year experience of reconstruction of the supra-aortic trunks.

DESIGN

Retrospective study.

SETTING

Teaching hospital, The Netherlands.

SUBJECTS

47 patients who required reconstruction of the supra-aortic trunks for stenotic or occlusive disease between April 1987 and May 1997.

INTERVENTIONS

Right-sided bifurcation graft through a sternotomy (n = 25), left-sided thoracotomy (n = 1), and extra-anatomic bypass (n = 21).

MAIN OUTCOME MEASURES

Morbidity, mortality, and long term patency.

RESULTS

3 patients died (6%); 7 (15%) developed major complications (leak from the brachiocephalic stump, n = 2, and acute occlusion of the bypass graft, n = 5) all of which were successfully treated by immediate reoperation; and 9 (19%) developed minor complications, all of which resolved within 3 months. The median follow up was 36 months (range 1-108), and the 3-year patency rate was 80%. No patient died during the follow up period, but a further 3 were lost to follow up. The remaining 41 were all assessed by duplex scanning or angiography, and 3 required further operation for recurrent symptoms; 33 remained completely free of symptoms.

CONCLUSION

Symptomatic stenotic or occlusive lesions of the supra-aortic trunks can be treated with acceptable morbidity and mortality, giving long term benefit to patients.

Dobutamine-atropine stress echocardiography and clinical data for predicting late cardiac events in patients with suspected coronary artery disease

PURPOSE

To compare the relative value of clinical variables with dobutamine-atropine stress echocardiography to predict cardiac events during long-term follow-up. Dobutamine stress echocardiography is increasingly used for the detection of coronary artery disease, but little is known of its prognostic value.

PATIENTS AND METHODS

A total of 430 patients (310 men; mean age 61 years, range 22 to 90) were enrolled in the study. Patients were referred for chest pain complaints and were unable to perform an adequate exercise stress test. All patients underwent dobutamine-atropine stress test (incremental dobutamine infusion: 10 to 40 micrograms/kg/minute, continued with atropine 0.25 to 1 mg intravenously if necessary to achieve 85% of the age predicted maximal heart rate, without symptoms or signs of ischemia) and clinical cardiac evaluation. Follow-up was 17 +/- 5 months, with a minimum of 6 months; 3 patients were lost to follow-up. Cardiac events were defined as cardiac death, nonfatal myocardial infarction, and coronary revascularization.

RESULTS

Seventy-nine cardiac events occurred in 76 patients: cardiac death (n = 11), nonfatal myocardial infarction (n = 18), and coronary revascularization (n = 50). By multivariate regression analysis, the prognostic value of the stress test in addition to common clinical variables was assessed. (1) Cardiac death was predicted by age greater than 70 years (odds ratio 5.6, 1.5 to 20) or new wall motion abnormalities in a study that is normal at rest (odds ratio 4.1, 1.1 to 15). (2) Death or myocardial infarction was predicted by a history of myocardial infarction (odds ratio 4.8, 1.8 to 13) or age greater than 70 years (odds ratio 2.3, 1.1 to 5.4), and the stress test outcome provided no additional information. (3) If all events were combined, only stress test results were prognostic: new wall motion abnormalities in a study that is normal at rest (odds ratio 3.1, 1.9 to 5.1), wall motion abnormalities at rest (wall motion score at rest > or = 1.12) (odds ratio 2.5, 1.4 to 4.0), or any new wall motion abnormalities during stress (odds ratio 2.0, 1.4 to 3.8). The positive predictive value of any new wall motion abnormality during stress for all late cardiac events was 25% (95% confidence interval [CI] 19 to 31) with a negative predictive value of 87% (95% CI 83 to 91).

CONCLUSION

In a large cohort of unselected patients with chest pain syndromes, new wall motion abnormalities induced by dobutamine provide additional information for late cardiac events, independent of clinical variables.