The Effect of Age on Peri-Operative Outcomes after FEVAR

INTRODUCTION

Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor.

METHODS

A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest.

RESULTS

During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest.

DISCUSSION

In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.

Fenestrated Endovascular Aortic Repair After Failed Endovascular Aortic Repair

PURPOSE

Fenestrated endovascular aortic repair (FEVAR) is technically more challenging when performed after a failing EVAR procedure (FEVAR after EVAR). This study aims to assess the technical outcome of FEVAR after EVAR and to identify factors that may influence complication rates.

METHODS

A retrospective observational study was conducted at a single department of vascular and endovascular surgery. The rate of FEVAR after EVAR compared to primary FEVAR is reported. Complication and primary unconnected fenestration (PUF) rates as well as survival were assessed for the FEVAR after EVAR cohort. PUF rates and operating time were also compared to all primary FEVAR patients. Patient characteristics and technical factors such as number of fenestrations or use of a steerable sheath were assessed as possible influencers on technical success when performing FEVAR after EVAR.

RESULTS

Two hundred and nine fenestrated devices were implanted during the study period (2013 to April 2020). Thirty-five patients (16.7% of all FEVAR patients) had undergone FEVAR after EVAR and were included in the study. Overall survival at last follow-up (20.2±19.1 months) was 82.9% in FEVAR after EVAR patients. Rates of technical failure dropped significantly after 14 procedures (42.9% vs. 9.5%; p=0.03). Primary unconnected fenestrations were seen in 3 cases of FEVAR after EVAR (8.6%) and 14 of 174 primary FEVAR cases (8.0%; p>0.99). Operating time for FEVAR after EVAR was significantly higher than for primary FEVAR (301.1±110.5 minutes vs. 253.9±103.4 minutes; p=0.02). The availability of a steerable sheath was a significant predictor of reduced risk of PUFs, whereas age and gender, number of fenestrations or suprarenal fixation of the failed EVAR did not significantly influence PUF rates.

CONCLUSION

Fewer technical complications were seen over the study period in FEVAR after EVAR patients. While rates of PUFs were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR can be a valuable and safe tool to treat patients with progression of aortic disease or type Ia endoleak after EVAR but may be more complex to achieve than primary FEVAR.

CLINICAL IMPACT

This retrospective study assesses the technical outcome of fenestrated endovascular aortic repair (fenestrated EVAR; FEVAR) after prior EVAR. While rates of primary unconnected fenestrations were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR after prior EVAR may be technically more challenging than primary FEVAR procedures, but could be performed with equally good results in this patient cohort. FEVAR offers a feasible treatment option for patients with progression of aortic disease or type Ia endoleak after EVAR.

Acute Kidney Injury and Mortality After Fenestrated Endovascular Aortic Repair

INTRODUCTION

Acute kidney injury (AKI) is a common complication following endovascular aortic repair (EVAR). An association of AKI with patient survival after fenestrated EVAR (FEVAR) is currently under investigation.

METHODS

Patients undergoing FEVAR between April 2013 and June 2020 were included in the study. AKI was defined according to acute kidney injury network criteria. Demographic and perioperative data, complications, and survival are reported for the study cohort. The data were analyzed to identify possible predictors of AKI.

RESULTS

Two hundred and seventeen patients underwent FEVAR during the study period. Survival at last follow-up (20.4 ± 20.1 mo) was 75.1%. Thirty patients experienced AKI (13.8%). Six of 30 patients with AKI (20%) died within 30 days or in-hospital and 1 (3.3%) progressed to hemodialysis. Within 1 y, renal function had recovered in 23 patients (76.7%). In-hospital mortality was higher in patients with AKI (20% versus 4.3%, P = 0.006). A higher rate of AKI was seen in patients in whom an intraoperative technical complication had been documented (38.5% versus 8.4%, P = 0.001).

CONCLUSIONS

Patients undergoing FEVAR are at risk of developing AKI, especially if they experience technical intraoperative complications. Most patients see recovery of renal function within the first 30 days to 1 y, but AKI remains associated with significantly increased in-hospital mortality.

Multicentre experience with an iliac fenestrated device

OBJECTIVES

The aim of this study was to present a multicentre experience of technical results and mid-term follow-up using a custom-made iliac fenestrated device (Terumo Aortic, Inchinnan, Renfrewshire, UK) for the treatment of iliac aneurysms and endoleaks.

METHODS

A multicentre retrospective evaluation of 22 patients (3-12 per institution) with either an iliac artery aneurysm or endoleak treated with an iliac fenestrated device was performed. Data were gathered from 3 departments of vascular and endovascular surgery at 3 European institutions.

RESULTS

Ten of the included patients (45.5%) were treated for an endoleak and 12 had aorto-iliac aneurysms (54.5%). Two patients underwent bilateral fenestrated device implantation for a total of 24 devices included in this analysis. Primary technical success was 91.7% (22 of 24 implanted devices). One of the 24 internal iliac arteries could not be cannulated and was covered (primary assisted technical success rate 95.8%) and 1 patient required a relining of the stent graft due to a mid-grade stenosis opposite the internal iliac artery fenestration. Survival at the last available follow-up (mean 15.2 ± 12.0 months, range 0.5-36.6 months) was 90.9%.

CONCLUSIONS

The present investigation adds to a growing body of literature on custom-made endografts and their usefulness in achieving endovascular repair without compromising blood flow via important arterial branch vessels, such as the internal iliac artery. It presents encouraging technical and mid-term follow-up data from consecutive patients treated for iliac aneurysms or endoleaks using this custom-made device. The technique may help avoid adverse sequelae associated to a coil-and-cover approach when iliac branch devices are not feasible.

Ultrasound-Guided Percutaneous Arterial Puncture and Closure Device Training in a Pulsatile Model

OBJECTIVE

The current study assesses the feasibility of in vitro practice of percutaneous puncture techniques in a pulsatile flow-model.

DESIGN

Prospective, controlled, randomized study.

SETTING

The percutaneous access to endovascular aortic repair is considered safe, but success rates may be dependent on surgeon experience with the technique.

PARTICIPANTS

Fourteen vascular surgery trainees and consultants were enrolled and randomized to a study or control group with both groups receiving instructions by a tutor on how to perform ultrasound guided percutaneous puncture and closure using a suture-mediated closure device. The study group received additional hands-on training on a pulsatile flowmodel of the groin and the performance of both groups was then graded. Study group participants were timed during and after their training on the model.

RESULTS

The study group achieved higher overall grading than the control group on a 5-point scale with higher scores indicating a better performance (mean overall scores 4.0 ± 0.7 versus 2.8 ± 1.0, respectively; p = 0.03). Experienced participants (more than 20 punctures performed before the study) achieved higher overall scores than trainees (3.8 ± 0.4 versus 2.5 ± 0.8, respectively; p = 0.01). Five participants in the study group could deploy and close the ProGlide closure device correctly without the help of a tutor while being graded (71% in the study versus 0% in the control group; p = 0.02). Study group participants improved their overall score from 3.2 ± 0.9 to 4.0 ± 0.7 during training (p = 0.02). Time needed to complete the puncture and closure reduced from 456 seconds on average before, to 302 seconds after training (p < 0.001).

CONCLUSIONS

Study group participants could improve their overall score while working on the simulator. More experienced participants performed better during the simulation, which may indicate the model to be life-like and a potential skills assessment tool. Simulation training may be a valuable adjunct to traditional forms of training when teaching an endovascular technique but is limited by its reliance on simulators and demo devices.

Custom-Made Iliac Fenestrated Device

Iliac branch devices (IBDs) are undergoing rapid popularization. They allow for treatment of an iliac aneurysm while preserving blood flow to the hypogastric artery. Certain anatomic criteria are necessary for the use of an iliac side branch device to be technically feasible. Custom-made fenestrated iliac stent grafts may provide an alternative when anatomic criteria for an IBD are not met.

Assessing the institutional learning curve for pararenal aortic repair using the fenestrated Anaconda endograft

Objective

Custom-made fenestrated aortic endografts allow exclusion of pararenal aortic aneurysms while maintaining blood flow to aortic branches. Meticulous device planning and precise deployment of the main body are essential to allow successful cannulation of the fenestrations. This study investigates whether a learning curve can be observed with more reliable cannulation and connection of fenestrations over time at a single department of vascular and endovascular surgery with multiple surgeons trained to use the device.

Methods

A retrospective analysis of data from all patients undergoing primary fenestrated endovascular aneurysm repair during the study period was performed. Outcome measures included case volume and average number of fenestrations over time, average fluoroscopy dose area product per calendar year and primary unconnected fenestration and 30-day mortality rates.

Results

Between 1 January 2013 and 31 December 2016, 89 patients with no history of endovascular aneurysm repair underwent fenestrated endovascular aneurysm repair at our institution. The number of fenestrations per case increased over time, averaging 2.6 in 2013 and 3.3 in 2016. Primary unconnected fenestration and 30-day mortality rates were 5.6%. Primary-assisted technical success was 93.3%, secondary-assisted technical success was 94.4%. Fluoroscopy dose area product declined over the study period. Thirty-day mortality and primary unconnected fenestration rates did not significantly change over the study period.

Conclusion

Albeit the reduction in lethal complications and primary technical success rates were not statistically significant, a lower percentage of unconnected fenestrations and 30-day mortality per calendar year were observed over time. At the same time, an increasing complexity of performed cases, as reflected by an increasing number of fenestrations per case, was observed. Complications associated with this complex endovascular procedure are potentially lethal and remain an unfortunate reality and may not be entirely dependent on overcoming a learning curve. A higher volume of cases performed over the study period and a reduction in fluoroscopy use can be considered a representation of the institutional development and learning curve for the Anaconda fenestrated endograft at a department with prior complex endovascular aortic repair experience, but due to limitations of the current retrospective observation, deserve further consideration in future trials, ideally designed in a prospective fashion.

Off-Label Iliac Side Branch Application for Salvage of an Accessory Renal Artery

Purpose: To present the off-label use of an iliac side branch device to connect an accessory right renal artery to a bifurcated endograft in infrarenal aortic aneurysm repair. Case Report: An 83-year-old woman with a 54-mm infrarenal abdominal aortic aneurysm underwent endovascular repair using an iliac side branch device for accessory renal artery salvage. The procedure was technically successful, and no immediate perioperative adverse events were encountered. The creatinine level increased slightly. Six-month follow-up imaging revealed no endoleaks or occlusion. Conclusion: Considering the higher perioperative risk associated with open or hybrid procedures for similar cases, this off-label application of a well-recognized endovascular device deserves consideration as an alternative treatment option.

Prevalence of erectile dysfunction in vascular surgery patients

Erectile dysfunction (ED) is frequently associated with cardiovascular disease. Epidemiological data on the frequency of ED in vascular surgery patients is rarely reported. We evaluated the prevalence of this comorbidity in patients consulting the vascular surgery outpatient clinic. Over a 6-month period, a short version of the International Index of Erectile Function (IIEF) questionnaire consisting of six EDrelevant questions was handed out to 440 vascular surgery outpatients. Clinical data were collected from patients' records. Linear regression models with forward selection were used to investigate associations between erectile function score and possible risk factors. The return rate was 31% (137 patients). Eight patients (6%) were taking phosphodiesterase inhibitors. ED, as defined by an erectile function score of 25 or less and/or use of phosphodiesterase inhibitors, was found in 90% (95% CI: 84% to 95%) of cases. Moderate or severe ED, as defined by an erectile function score of 16 or less and/or use of phosphodiesterase inhibitors, was found in 70% (95% CI: 62% to 78%) of cases. Increased age, abdominal aortic aneurysm, peripheral arterial disease, urologic disease, insulin-dependent diabetes mellitus, and use of beta-blockers were significantly associated with a lower erectile function score. In conclusion, erectile dysfunction is a frequent and often missed comorbidity in vascular surgery patients. While ED may have a profound impact on the patient's quality of life, attention should also be paid to the patient's preoperative sexual function, considering the availability of oral pharmacotherapies and possible consequences concerning liability in postoperative patients in whom pre-existing ED was not identified properly.

Natural History of the Iliac Arteries after Endovascular Abdominal Aortic Aneurysm Repair and Suitability of Ectatic Iliac Arteries as a Distal Sealing Zone

Purpose:

To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs.

Methods:

Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs ≤16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b).

Results:

The mean CIA diameter increased by 1.0±1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5±1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6±18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed.

Conclusion:

Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

Paravertebral Blockade with Propofol Sedation versus General Anesthesia for Elective Endovascular Abdominal Aortic Aneurysm Repair

The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA).

Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications.

Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension ( p < .05) and blood pressure lability ( p < .01), as well as postoperative nausea ( p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.

[Aortofemoral vascular graft infections and their prevention]

Vascular prosthesis infections are potentially severe adverse events following vascular reconstruction. They are often associated with a high morbidity and mortality, especially in the aortofemoral region. The present article outlines the diagnosis, prevention and treatment of vascular graft infections in a clinical setting. The clinical presentation, inflammatory markers, microbiological work-up and imaging studies can contribute to diagnosing a prosthesis infection. Regarding the bacterial spectrum involved in the etiology of prosthesis infections, single organism infections (monoinfections) have become less significant over the past years, whereas infections with multiple organisms now constitute the most abundant microbiological constellation. Also, infections with resistant bacterial strains have been increasing in number over the past years and deserve special consideration. It remains unclear whether both aspects are due to a true epidemiological change or are the result of advanced molecular microbiological diagnostic methods. While during the past decades perioperative antibiotic prophylaxis was regarded as the most important measure for preventing prosthesis infections in vascular surgery, other primary preventive hygiene strategies have been increasingly explored and grouped together in the sense of preventive bundles. In most cases of deep postoperative infections involving a prosthetic device in the aortofemoral region, explantation of the prosthesis will be required. In situ and extra-anatomical reconstructions are often performed in such cases and the decision process to develop an optimal treatment plan must consider several individual factors. In select patients, palliative preservation of the prosthesis despite surrounding infection (i.e. graft salvage) and best conservative management in combination with local surgical measures, such as incision and drainage and vacuum therapy, deserve consideration as a treatment option for patients with a high surgical risk.

Austrian national carotid intervention numbers prompt improvement in secondary stroke prevention

BACKGROUND

As recent data suggest a variable benefit of carotid endarterectomy (CEA) or stenting (CAS), a careful selection of patients is mandatory for efficient stroke prevention. This retrospective study analyzed carotid intervention rates from 1999-2008 in Austria. The aim was to assess whether interventions for carotid stenosis were performed with respect to epidemiological trends and published data taking into account intervention type, age and gender.

METHODS

Intervention numbers for internal carotid artery (ICA)-stenosis from a 10 years period (1999 to 2008) were retrieved from the national Austrian registry for hospital funding. Patients were grouped by gender, age (0-64, 65-74, older than 75 years) and intervention type.

RESULTS

CEA rates amounted to 32.2±1.4 per 100000 persons annually (female: 22.1±0.7, male: 43.0±2.3). Each year 9.1 CAS±1.6 per 100000 Austrians were performed (female: 9.3±1.8, male 8.9±1.7). CAS numbers increased (P<0.05), whereas CEA numbers stagnated, especially in older age groups. Women were more likely to undergo CAS than CEA compared to men.

CONCLUSION

Relative intervention rates for carotid stenosis have rather stagnated, although stroke incidence increases continuously in an overaging society. Despite controversial data, CAS rates have been rising constantly in elderly women. Secondary stroke prevention in Austria can be improved by a careful selection of future patients, especially with regard to female gender and type of intervention.

Indications and techniques for emergency carotid interventions

Mutual understanding exists among specialists of neurology, interventional radiology and vascular surgery concerning the need of interventional treatment for patients with symptomatic carotid artery stenosis. However, identification of individuals that will most likely benefit from treatment, timing of the intervention and selection of treatment mode continue to be a matter of intense debate. The aim of this manuscript was to discuss the changing attitude to this high-risk population and present evidence that points towards a resolute, fast-track approach.

Reliability of constant-load treadmill testing in patients with intermittent claudication

AIM

Constant-load treadmill testing is frequently used to estimate walking ability of patients with peripheral arterial disease and to assess changes in functional capacity following therapeutic interventions or through disease progression. The value of this test has frequently been disputed based on doubts concerning its reproducibility. The aim of this study was to investigate the reliability of treadmill testing at a speed of 3 km/h and a constant inclination of 12%.

METHODS

Sixty-eight patients with stable peripheral arterial disease who were familiar with treadmill testing underwent two sessions of walking exercise at 3 km/h and 12% inclination within three weeks. Initial claudication distance (ICD) and maximum walking distance (MWD) on the treadmill as well as reported walking distances on level ground at individual speed were recorded.

RESULTS

Correlation coefficients of 0.8 and within-subject variation coefficients of 15% for ICD and 13% for MWD demonstrated low variability of walking distances between visits. No learning effects were observed. Intra-class correlation coefficients of 0.78 for ICD and 0.83 for MWD proved good reproducibility of treadmill testing. Correlation of measured and reported walking distances was poor.

CONCLUSION

Constant-load treadmill testing at 3km/h and 12% inclination is a well reproducible method to investigate walking capacity of patients with stable intermittent claudication who are familiar with this test method. From treadmill walking distances, no conclusions should be drawn concerning the actual walking range of the patient.

Abdominal Aortic Aneurysms

Abdominal aortic aneurysms represent both an individual risk of mortality and a socioeconomic burden for health care systems worldwide, but screening is not performed in all countries. Here, the authors summarize the pros and cons of screening to reduce abdominal aortic aneurysm–related mortality.

Local anesthesia and exposure for carotid endarterectomy: background and technical realization

While carotid endarterectomy is an established method for the treatment of symptomatic as well as high-grade asymptomatic carotid artery stenoses, there is a considerable variation concerning the kind of anesthesia used as well as technical details of the operation. In the present article differing arguments on local versus general anesthesia as well as a transverse versus a longitudinal skin incision will be discussed. Furthermore, possible access routes to the carotid bifurcation, the retrojugular compared to the ventrojugular approach, will be presented in detail.

Intraoperative gamma probe localization of the ureters: a novel concept

BACKGROUND

Ureteral stent placement to localize the ureters during operations is an invasive procedure. The aim of this study was to evaluate the feasibility of using the gamma probe to intraoperatively identify the ureters after intravenous injection of a radiopharmaceutical agent.

STUDY DESIGN

Ten patients undergoing elective abdominal operations were prospectively enrolled in this study. An average dose of 4.5 mCi (range 2.8 to 5.3 mCi) of technetium Tc 99m-labeled diethylenetriamine pentaacetic acid ((99m)Tc-DTPA) was administered intravenously before localization of the ureters. The gamma probe was used to localize the ureters. Correct identification of the ureters was confirmed when gentle manipulation induced a typical ureteral peristaltic pattern.

RESULTS

Gamma counts were significantly elevated in all ureters examined. Compared with background counts, gamma counts were increased over the ureter in all patients, with an average increase of 465%. The technique was modified after use in the first 3 patients and standardized for patients 4 through 10. Data from those seven patients were analyzed. Both ureters were correctly identified using the gamma probe at a mean of 15 minutes (median, 10 minutes) after a single (99m)Tc-DTPA injection (range 4 to 41 minutes). The mean background count was 80 counts per second (cps, range 50 to 130 cps). The mean ureter count was 393 cps (range 128 to 700 cps). The average percent increase of each ureter count compared with its specific background count was 465% (range 256% to 1,077%). The difference was statistically significant for all values (p < 0.001).

CONCLUSIONS

This novel technique of gamma probe localization of the ureters may offer a noninvasive approach for ureteral identification.

Abdominal aortic aneurysm neck remodeling after open aneurysm repair

PURPOSE

Proximal endovascular aortic graft fixation and maintenance of hemostatic seal depends on the long-term stability of the aortic neck. Previous investigations of aortic neck dilation mostly focused on the infrarenal aortic diameter. Fenestrated and branched stent grafts facilitate suprarenal graft fixation and may thereby improve the long-term integrity of the aortic attachment site. For these devices, the natural history of the suprarenal aortic segment is also of interest. We investigated the natural history of the supra- and infrarenal aortic segment after open abdominal aortic aneurysm (AAA) repair.

METHODS

For this retrospective analysis, we reviewed the preoperative and the initial postoperative as well as the most recent CT series that were obtained from 52 patients undergoing conventional repair of an infrarenal abdominal aortic aneurysm between January 1998 and December 2002. Measurements were performed using electronic calipers on a "split screen", allowing direct comparison of subsequent CT series at corresponding levels along the vessel. Main outcome measures were changes in postoperative measures of the supra- and infrarenal aortic diameters.

RESULTS

The first postoperative exam was at a mean (+/-SD) of 7.0 +/- 3.5 months, and the final exams were at 44.4 +/- 21 months. Over this time period, the estimated rate of change in suprarenal diameter was 0.18 mm/ y with 95% confidence interval (CI) from 0.08 to 0.27. The estimated rate of change for the infrarenal diameter was 0.16 (95% CI: 0.05 to 0.27). A clinically relevant diameter increase of >or=3 mm was observed in seven patients (13%). There was evidence of larger diameter increases associated with larger AAA diameters (P = .003 and <.001 for suprarenal and infrarenal diameters), an inverted funnel shape (P = .002 and <.001), and marginal evidence of association with a history of inguinal hernia (P = .043 and .066).

CONCLUSIONS

Although there is statistically significant evidence of increases in the supra- and infrarenal aortic diameters after conventional AAA repair, mean annual increases tended to be small and clinically relevant increases of 3 mm or more were observed in only a small proportion of cases.

Successful liver transplantation and treatment of recurrent hepatitis C using pegylated alpha-interferon in a patient with Churg-Strauss disease

Churg-Strauss disease (CSD) is a rare allergic disorder that is associated with vasculitis, peripheral eosinophilia and allergic asthma. We report on successful liver transplantation in a patient with CSD who suffered from chronic hepatitis C. Recurrent hepatitis C and CSD were ultimately managed by the application of pegylated interferon.

Common Carotid Artery Imbrication as an Adjunct to Carotid Endarterectomy to Prevent Postoperative Carotid Kinking

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 ± 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1–58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

Common carotid artery imbrication as an adjunct to carotid endarterectomy to prevent postoperative carotid kinking

Mobilization of a tortuous carotid artery during endarterectomy may produce redundancy of the carotid artery, and kinking. We reviewed our experience with common carotid artery (CCA) imbrication as a technique to shorten the common and internal carotid artery postendarterectomy and to avoid carotid kinking. A retrospective chart review of 163 patients who underwent carotid endarterectomy by the same surgeon between August 1998 and February 2006 was performed. All patients underwent conventional endarterectomy via a longitudinal arteriotomy with an indwelling shunt and patch angioplasty. Patients undergoing concomitant carotid artery imbrication were identified. Twelve patients who underwent carotid imbrication were identified. The mean age was 74.9 +/- 8.8 years. Nine patients underwent imbrication of the CCA, and in three cases, the internal carotid artery was plicated. Follow-up duplex ultrasound examinations were available for 10 individuals and mean follow-up time was 10.7 months (range, 1-58 months). There were no cases of peri- or postoperative cerebral accidents and there was no case of restenosis. CCA imbrication as an adjunct to carotid endarterectomy is a feasible technique in preventing postoperative carotid kinking.

Endovascular repair of an infrarenal abdominal aortic aneurysm with a dominant middle mesenteric artery: A case report

The middle mesenteric artery is a rare anomalous mesenteric vessel that may supply variable segments of the colon. Occlusion of this artery during endovascular aortic aneurysm repair may bear a significant risk of bowel ischemia. We report the successful interventional treatment of a patient with a 5.3 cm infrarenal abdominal aortic aneurysm, sparing a dominant middle mesenteric artery.

Surgical and medical management of mesenteric ischemia

Acute mesenteric ischemia frequently results in bowel necrosis, which necessitates laparotomy to assess bowel viability. Reduction in mortality requires a high index of suspicion and prompt diagnosis. Bowel resection should be preceded by visceral artery revascularization. Medical management includes the use of anticoagulation, vasodilators, and the use of inhibitors of reperfusion injury. The management of chronic mesenteric ischemia largely depends on the general condition of the patient, who is often affected by malnutrition and dehydration. Surgery, although associated with greater morbidity and mortality, is more durable and effective in relieving the symptoms of chronic mesenteric ischemia. Endovascular treatment options for chronic mesenteric ischemia include percutaneous balloon angioplasty and stenting. This treatment is more likely to be successful in dealing with stenotic rather than occlusive lesions and offers a minimal invasive approach but is associated with a smaller primary success rate and a higher recurrence rate.

Successful treatment of a tuberculous vertebral osteomyelitis eroding the thoracoabdominal aorta: A case report

Mycotic aortic aneurysms are rare complications of systemic tuberculosis that affect very few patients. We report a case of a false aneurysm of the visceral segment of the aorta that was associated with tuberculous vertebral osteomyelitis. Both conditions were successfully treated with antituberculous chemotherapy and a combined surgical procedure, ie, aneurysm resection and homograft implantation, followed by orthopedic stabilization of the spine.

Lack of seasonal variation in flow-mediated dilatation of the brachial artery in women with primary Raynaud's phenomenon and healthy controls

BACKGROUND

The aim of this study was to examine endothelium function and seasonal variations of endothelium function in women with primary Raynaud's phenomenon (RP) and healthy controls.

PATIENTS AND METHODS

After a fast of at least 8 hours we studied 21 patients with primary RP (mean age 31.1 years, mean duration of RP 9.1 years) and 22 controls (mean age 27.8 years) by use of high resolution brachial artery sonography in winter (December/January 2000) and summer (July/August 2001). To exclude circadian variations all examinations were performed in the late afternoon only. All subjects were non-smokers. Confounding factors like serum glucose, HbAlc, and lipid concentrations were analyzed immediately before the investigations. Nicotine contamination was randomly analyzed in hair samples in 8 subjects of each study group. Flow mediated dilatation (FMD%) and nitroglycerin induced dilatation (NID%) were calculated by putting the basal vessel diameter as 100%.

RESULTS

Basal, flow-mediated, and nitroglycerin-induced absolute diameters of the brachial artery did not differ significantly between the study groups (p = 0.85). The test conditions (basal, postocclusive, nitroglycerin-induced) always let to the same vessel response in winter and summer (p = 0.61) and there was no significant influence between these test conditions and the study groups (p = 0.07). Compared to patients FMD% was slightly reduced in controls in summer (p = 0.09). Analysis of variance excluded a significant relation between study group and season (p = 0.43). For NID% too, no statistically significant differences were found.

CONCLUSIONS

We were not able to show impaired or seasonally variant flow-mediated or nitroglycerin-induced dilatation of the brachial artery in patients with primary RP. Our results argue against the presence of a more generalized endothelium dysfunction detectable with high resolution ultrasound of the brachial artery in patients with primary RP.

Cardiac troponin and beta-type myosin heavy chain concentrations in patients with polymyositis or dermatomyositis

Cardiac troponin T (cTnT), cardiac troponin I (cTnI), myosin heavy chains (MHC), myoglobin, creatine kinase (CK), and creatine kinase isoenzyme MB (CKMB), were measured in blood samples from 39 polymyositis (PM) or dermatomyositis (DM) patients without clinical evidence for cardiac involvement to evaluate their clinical usefulness in this patient population. MHC, myoglobin, and CKMB were frequently elevated and correlated with each other and with disease severity. Undetectable cTnI in all but one patient indicated that MHC was released from skeletal muscle, thereby providing the first laboratory evidence of frequent slow-twitch muscle fibre-necrosis in patients with PM or DM. CKMB was elevated in 51%, cTnT in 41%, and cTnI in only 2.5% of patients. cTnI did not correlate with other markers or with disease severity scores. The close correlations found between cTnT and skeletal muscle damage markers and the relationship between cTnT with disease severity without clinical evidence for myocardial damage suggest a release of cTnT from skeletal muscle. The relationship of cTnT with disease severity indicates a possible role of the marker for risk stratification. However, the prognostic values of cardiac troponins and other muscle damage markers in PM/DM patients remain to be compared in prospective outcome trials.

Myocardial damage after minimally invasive coronary artery bypass grafting on the beating heart

BACKGROUND

In conventional coronary artery bypass grafting, the rate of perioperative myocardial infarction is reported in the 2% to 6% range; however, significantly higher rates are observed if sensitive myocardial marker proteins are used to detect perioperative myocardial damage. For minimally invasive direct coronary artery bypass grafting, few data are available concerning myocardial marker protein release.

METHODS

Fifteen consecutive patients (11 male, 4 female; mean age, 59.6 +/- 8.5 years) received minimally invasive direct coronary artery bypass grafting procedures via minithoracotomy on the beating heart. Electrocardiography and transesophageal and transthoracic echocardiography as well as determination of creatine kinase-MB mass concentration and cardiac troponin I level were used for ischemic monitoring.

RESULTS

One patient had a perioperative myocardial infarction according to standard criteria and died despite mechanical circulatory support. Determination of cardiac troponin I level showed small but definitive ischemic damage in 4 of 9 patients (44%) who presented transient ischemic signs intraoperatively or postoperatively. In 2 of these 4 patients pathologic findings could be detected on angiographic restudies.

CONCLUSIONS

Subclinical myocardial injury is a common event in minimally invasive coronary artery bypass grafting on the beating heart. Cardiac troponin I could serve as an adequate diagnostic tool for diagnosis of perioperative myocardial infarction in minimally invasive direct coronary artery bypass grafting.

Different intracellular compartmentations of cardiac troponins and myosin heavy chains: a causal connection to their different early release after myocardial damage

We investigated the net myocardial release of creatine kinase isoenzyme MB (CKMB), myoglobin, cardiac troponin T (cTnT), cardiac troponin I (cTnI), and cardiac beta-type myosin heavy chain (beta-MHC) into the coronary circulation after cardioplegic cardiac arrest in humans. Cardiac markers were measured in paired arterial, central venous, and coronary sinus blood in 19 patients undergoing elective coronary artery bypass grafting (CABG) before aortic cross-clamping and 1, 5, 10, and 20 min after aortic declamping. cTnT and cTnI were released into the coronary sinus in parallel to each other and almost simultaneously to myoglobin and CKMB within 20 min of reperfusion. In contrast, no beta-MHC was released in the same patients during the study period. The average soluble cTnT and cTnI pools in right atrial appendages of 11 patients with right atrial and right ventricular pressures within reference values were comparable and were approximately 8% of total myocardial troponin content. The soluble beta-MHC pool was <0.1% in all patients. Our results demonstrate the impact of the different intracellular compartmention of regulatory and contractile proteins on their early release from damaged myocardium.

No release of cardiac troponin I during major orthopedic surgery after acute normovolemic hemodilution

BACKGROUND

Normovolemic hemodilution is a well-accepted method for intraoperative blood salvage. However, some controversy exists concerning the possible risk of myocardial fiber injury as consequence of the reduced oxygen content. Laboratory diagnosis of perioperative myocardial fiber injury is difficult, since biochemical markers are elevated postoperatively due to the surgical trauma. Cardiac troponin I (cTnI) is a new, highly sensitive and specific marker for the detection of myocardial injury. The aim of our study was to investigate whether normovolemic hemodilution in patients with major orthopedic surgery (13 hemodiluted patients, 15 control) induces a release of cTnI.

METHODS

cTnI as a highly specific and sensitive cardiac parameter, as well as total creatine kinase (CK), creatine kinase isoenzyme MB mass (CKMB mass) and myoglobin were measured after induction of anesthesia, after normovolemic hemodilution, prior to retransfusion of blood components, 3 h after surgery, and on the first and third postoperative days.

RESULTS

Prior to retransfusion of blood components the hematocrit was decreased to 25.4 +/- 1.2% (mean +/- SEM; range: 18%-34%) in the control group and to 20.2 +/- 0.8% (mean +/- SEM; range: 17%-24%) in the hemodilution group. Total CK, CKMB mass as well as myoglobin concentration increased significantly in both groups, reaching their maxima within the first day of surgery. In contrast, cTnI was below the detection limit of assay (< 0.5 micrograms/L) at any time.

CONCLUSIONS

We suggest that pre- and intraoperative hemodilution to a hematocrit of approximately 20% by maintaining normovolemia does not induce myocardial fiber injury in patients without preexisting cardiac diseases.