This is an important article. These results will expand our knowledge, inform future study, and drive government policy. Critics will point out that the data set is flawed and that the application of the scoring system to the National Health and Nutrition Examination Survey (NHANES) data is speculative. They are correct on both counts, but these criticisms do not negate the value of this report.

Background: Axillosubclavian vein thrombosis, also known as Paget-Schroetter syndrome, is a rare presentation of thoracic outlet syndrome (TOS) representing approximately 5% of all cases. Conventional management consists of routine anticoagulation, operative decompression via first rib resection and scalenectomy (FRRS), and, recently, thrombolysis. The purpose of our study was to retrospectively review our experience with this condition and compare the effectiveness of preoperative endovascular intervention with thrombolysis and venoplasty to anticoagulation alone in those undergoing FRRS to preserve subclavian vein patency.Methods: A retrospective review was conducted for all venous TOS patients from July 2003 to May 2009 from a prospectively maintained database. Preoperative clinic notes were reviewed to allow stratification into two groups. One group consisted of patients undergoing preoperative endovascular intervention with thrombolysis and venoplasty, while the other group consisted of patients managed medically with anticoagulation alone prior to FRSS. Operative notes, postoperative venograms, and postoperative duplex imaging results were reviewed for presence of recanalization, chronic nonocclusive thrombus, or continued occlusion.Results: One hundred three patients had 110 FRRS for subclavian vein thrombosis (53 men, 50 women), seven of which had contralateral FRRS for thrombosis. The cohort averaged 31 years of age (range, 16-54 years) with an overall, mean follow-up time of 16 months (range, 1-52 months). Of the 110 veins evaluated, 45 underwent endovascular intervention (thombolysis, with or without venoplasty) prior to FRRS, and at 1 year, 41 (91%) were patent with improvement of symptoms. In the 65 veins on anticoagulation alone, 59 (91%) ultimately were patent, with symptomatic improvement in all. Overall, 91% (100/110) of subclavian veins were patent in patients completing follow-up, were asymptomatic, and back to their previous active lifestyle.Conclusions: Preoperative endovascular intervention offered no benefit over simple anticoagulation prior to FRRS, since the use of thrombolysis prior to FRRS, regardless of need for postoperative venoplasty, had little impact on overall rates of patency. The optimal treatment algorithm may merely be routine anticoagulation for all effort thrombosis patients prior to FRRS followed by venography with venoplasty if needed. The role of thrombolysis for Paget-Schroetter syndrome should be further investigated in randomized trials.

Dr L. Richard Sprouse (Chattanooga, Tenn). Thank you. First of all, I would like to thank the authors for providing me with this manuscript before the meeting. I haven't noticed any major changes compared to the original abstract that was submitted to the Southern Association for Vascular Surgery, and I would like to congratulate Dr Guzzo on an outstanding presentation.

Background: Patients with critical limb ischemia (CLI) have a high rate of adverse cardiovascular events, particularly when undergoing surgery. We sought to determine the effect of surgery and vascular disease on platelet and monocyte activation in vivo in patients with CLI.Methods: An observational, cross-sectional study was performed at a tertiary referral hospital in the southeast of Scotland. Platelet and monocyte activation were measured in whole blood in patients with CLI scheduled for infrainguinal bypass and compared with matched healthy controls, patients with chronic intermittent claudication, patients with acute myocardial infarction, and those undergoing arthroplasty (n = 30 per group). Platelet and monocyte activation were quantified using flow cytometric assessment of platelet-monocyte aggregation, platelet P-selectin expression, platelet-derived microparticles, and monocyte CD40 and CD11b expression.Results: Compared with those with intermittent claudication, subjects with CLI had increased platelet-monocyte aggregates (41.7% ± 12.2% vs 32.6% ± 8.5%, respectively), platelet microparticles (178.7 ± 106.9 vs 116.9 ± 53.4), and monocyte CD40 expression (70.0% ± 12.2% vs 52.4% ± 15.2%; P < .001 for all). Indeed, these levels were equivalent (P-selectin, 4.4% ± 2.0% vs 4.9% ± 2.2%; P > .05) or higher (platelet-monocyte aggregation, 41.7% ± 12.2% vs 33.6% ± 7.0%; P < .05; platelet microparticles, 178.7 ± 106.9 vs 114.4 ± 55.0/μL; P < .05) than in patients with acute myocardial infarction. All platelet and monocyte activation markers remained elevated throughout the perioperative period in patients with CLI (P < .01) but not those undergoing arthroplasty.Conclusions: Patients undergoing surgery for CLI have the highest level of in vivo platelet and monocyte activation, and these persist throughout the perioperative period. Additional antiplatelet therapy may be of benefit in protecting vascular patients with more severe disease during this period of increased risk.Clinical Relevance: Peripheral arterial disease is increasingly common and is associated with a significant risk of cardiovascular complications, especially at the time of surgery. Despite this, patients are poorly provided with evidence-based therapies such as antiplatelet and lipid-lowering medications. Platelets play a key role in the pathogenesis of atherothrombosis, with elevated levels of in vivo platelet activation prognostic of adverse clinical events. This study demonstrates, for the first time to our knowledge, significantly greater levels of platelet activation in patients with severe peripheral arterial disease compared with patients with acute myocardial infarction or patients undergoing other moderate- to high-risk surgical procedures. This further emphasizes the need for improved risk stratification and cardioprotection of this vulnerable group.

This article presents one institution's outcomes with infrainguinal arterial reconstruction using arm vein and prosthetic conduits. Coding for lower extremity arterial revascularization is based on inflow artery, outflow artery, and conduit. There is no difference between the above-knee and the below-knee popliteal artery for billing purposes. Additionally, “femoral” in the CPT descriptions denotes either the common, superficial, or deep femoral artery. Conduit options include “vein”, “in-situ saphenous vein”, and “other than vein”. “Vein” comprises harvest and preparation of saphenous vein from the same or opposite leg, whether it is reversed or left in an orthograde configuration. No extra coding is available for rendering valves incompetent. “Other than vein” is appropriate when prosthetic material (eg, Dacron or expanded polytetrafluoroethylene), umbilical vein, cryopreserved vein, or an excised artery (eg, radial or hypogastric) is utilized. Based on the introductory wording in the subsection entitled “Arteries and Veins” within the “Cardiovascular System” segment of the CPT manual, all manipulation for the purpose of “establishing both inflow and outflow by whatever procedures necessary” is bundled. Therefore, endarterectomy or patch angioplasty at the inflow/outflow vessel anastomosis is not separately reportable. National Correct Coding Initiative (NCCI) edit pairs have been created to that end.

This article evaluates patients with superficial venous insufficiency due to greater saphenous vein incompetence treated with endovenous ablation. Open surgical venous intervention on saphenous vein pathology has been discussed in a previous article. Endovenous ablation therapy CPT coding was introduced in 2005. The two treatment technologies both involve catheter-based venous access under ultrasound guidance but impart thermal energy using different modalities to the vein wall: namely, radiofrequency or laser. Therefore, there are two sets of code descriptions available. Radiofrequency uses CPT code 36475, which states “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated”, while laser relies upon CPT code 36478, which denotes “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated”. The majority of cases use this technology on the greater saphenous vein. However, the lateral accessory saphenous vein and the lesser saphenous vein are alternatives based on clinical indication. If two or more of these veins are ablated in the same setting, add-on codes have been created to describe the additional work. CPT code 36476 depicts “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)”, while CPT code 36479 states “endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)”. In CPT wording, “second and subsequent” means that the code is reported only once per session regardless of the number of veins treated. For example, if two veins are treated with radiofrequency in the same leg, CPT codes 36475 and 36476 would be submitted to the insurance carrier. If three or more veins are treated in the same leg and in the same setting, the billing is identical to the “two vein scenario” above (CPT code 36476 is not reported more than once or with a unit value greater than one). However, bilateral intervention requires the −50 modifier (bilateral procedure) and is applicable to all four vein ablation codes listed above.

Conclusion: Carotid artery angioplasty and stenting can be successfully performed in patients with internal carotid artery pseudo-occlusion or string sign. Summary: This report focuses on carotid angioplasty and stenting in a series of patients in whom the internal carotid artery (ICA) was thought occluded by conventional ultrasound but who actually had string signs. The authors treated 16 patients. Contrast computed tomography (CT) showed a patent distal ICA in 14 of the 16 patients treated. Contrast-enhanced ultrasound imaging also showed patent distal ICAs in 13 cases.

Conclusion: Basilic vein transposition fistulas have excellent maturation rates and good functional patency at 1 year. Major limitations to long-term durability are the need for frequent revisions and central venous stenosis.

Conclusion: Patients with chronic renal failure have decreased responsiveness to clopidogrel compared with patients without chronic renal failure. This decreased responsiveness is not corrected by an increase in the clopidogrel dosage.

Conclusion: Carotid plaque thickness in a multiethnic cohort is associated with a quantitative weighted index of infectious burden derived from the magnitude of association of individual infections with stroke.

Conclusion: Transient ischemic attacks (TIAs) marked by limb-shaking are associated with high-grade carotid stenosis or internal carotid artery occlusion and can be recognized by short duration and precipitation by rising or exercise. They are also accompanied frequently by paresis and indicate an impaired hemodynamic state of the brain.

Conclusion: In a substudy of patients randomized in the International Carotid Stenting Study (ICSS) comparing carotid artery stenting with carotid endarterectomy for symptomatic carotid stenosis, patients randomized to the stenting group had three times more ischemic lesions found by post-treatment magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI) than patients randomized to the endarterectomy group. Cerebral protection devices did not seem to be effective in preventing ischemic DWI lesions after stenting.

Conclusion: Within 4 years of acute pulmonary embolism (PE), half the patients will have an additional serious adverse clinical event. Summary: Most articles on acute PE focus on incidence and case fatality rates. There are little data on the long-term fate of the patients. This report, however, does provide a more long-term perspective of the fate of patients with PE. We know that death related to PE occurs in approximately 2% to 6% of patients with a hemodynamically stable PE and in >30% of patients with PE presenting with shock or hemodynamic instability (Chest 2002;121:877-905; Arch Intern Med 2004;164:92-96). About 25% of patients do not survive the first year after the diagnosis of PE, with most deaths relating to cancer or chronic heart disease rather than to PE itself (N Engl J Med 1992; 326:1240-1245). We also know that patients with PE are at risk for recurrent PE, chronic thromboembolic pulmonary hypertension, arterial cardiovascular events, and a new diagnosis of cancer (N Engl J Med 1998;338:1169-73; AMA 2005;293:2352-61). The goal of this study was to assess long-term risk for adverse events after PE.

Conclusion: In patients with symptomatic or asymptomatic carotid stenosis, a composite outcome of stroke, myocardial infarction, or death does not differ between patients undergoing endarterectomy or those undergoing carotid artery stenting. During the periprocedural period, there is a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy.

Background: Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure.

Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40–80% and mortality rate of 25–60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

Objectives: Endovascular aneurysm repair (EVAR) is an established method of aortic aneurysm repair, in favourable anatomical configurations. It does however expose patients to radiation. The study aim was to determine if the aneurysm neck morphology influenced radiation exposure.

Purpose: The proximal abdominal aortic aneurysm (AAA) neck expands significantly during the cardiac cycle, both before and after endovascular aneurysm repair (EVAR). Clinical consequences of this pulsatility were anticipated but have never been reported. This study investigated whether there is a relation between stent graft migration and preoperatively measured pulsatility of the proximal aneurysm neck.

Objectives: Endovascular aneurysm repair for abdominal aortic aneurysm (AAA) is now a widely adopted treatment. Several complications remain to be fully resolved and perhaps the most significant of these is graft migration. Haemodynamic drag forces are believed to be partly responsible for migration of the device. The objective of this work was to investigate the drag forces in patient-specific AAA stent-grafts.

Objectives: To investigate the diagnostic accuracy of fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) compared with computed tomography (CT) scanning and added value of fused FDG-PET–CT in diagnosing vascular prosthetic graft infection.