Objective: In contrast to endovascular repair (EVAR), the absence of rigorous imaging follow-up after open surgical repair (OSR) has rendered the perception that late failure (LF) is rare. Better understanding of associated factors with LF will help define OSR follow-up paradigms and perhaps alter initial repair strategy to facilitate treatment of LF. The aim of this study is to evaluate aspects of LF requiring intervention after OSR.Methods: From 1998 to 2008, data were collected prospectively on 1097 patients who underwent an aortic endovascular repair. Patients undergoing intervention for LF contiguous with prior OSR were subjected to further analysis. The indication for reintervention was a maximal diameter >60 mm. Univariable and multivariable linear regression models were used to compare patients and disease variables (18 variables regarding age, comorbidities, family history, etiology, and extent) with time to LF.Results: LF of open surgical aneurysm repair was identified in 104 (9.5%) patients. Mean aneurysm diameter was 72 ± 12 mm. Mean age at first repair and time between the two repairs were 61.4 ± 10.0 and 10.8 ± 6.0 years, respectively. When compared with the 993 other patients whose EVAR was their primary repair, LF patients were significantly younger at the time of their first repair (61.4 ± 10.0 vs 74.1 ± 9.6 years; P < .00001) and more frequently had a family history of aneurysms (20% vs 7%; P = .001). They were also more likely to have presented with dissection, renal insufficiency, and manifestations of atherosclerosis. On multivariable analysis, patients with an initial incomplete OSR (aneurysm located in another aortic segment but not treated at the time of the primary repair), more extensive aneurysms (those involving the descending thoracic or the thoracoabdominal aorta), and older patients experienced earlier LF (P < .00001, .002, and .001, respectively). Although we were incapable of determining the incidence of LF after OSR, 34% of patients presenting with LF were regional to our center.Conclusion: Aneurysmal disease is an ongoing process potentially involving the entire aorta. Segments that appear normal prior to OSR of EVAR may be vulnerable to LF. We identified several groups of patients following OSR who mandate more aggressive follow-up given their propensity to present with LF. The threshold and strategies guiding reintervention in the setting of LF is dependent upon many factors relating to the structure and the morphology of the aorta and implanted graft, the type of anastomosis, and patient comorbidities. Therefore, surgeons should consider LF treatment options when planning an aneurysm repair in an effort to optimize any later interventions, and have specifically tailored follow-up paradigms.

Objective: Endovascular aneurysm repair (EVAR) exposes patients to radiation during the procedure and in subsequent follow-up. The study goal was to calculate the radiation dose in our unit and compare it against other published data and national guidelines.Methods: All EVAR procedures were identified from a prospectively maintained database. Radiation dose, screening time, and volume of intravenous contrast during the procedure were reviewed. Radiation exposure from subsequent computed tomography (CT) imaging was included in the overall exposure. Results are expressed as mean ± standard deviation.Results: From October 1998 to October 2008, 320 elective patients underwent EVAR. Mean screening time was 29.4 ± 23.3 minutes, and the radiation dose was 11.7 ± 7.1 mSv. The EVAR was an emergency in 64 patients. The mean screening time was 22.9 ± 18.2 minutes, and the radiation dose was 13.4 ± 8.6 mSv. During the first postoperative year, follow-up CT scans exposed the patients to 24.0 mSv, with 8.0 mSv in subsequent years. Abdominal radiographs added an additional 1.8 mSv each year.Conclusion: EVAR and the follow-up investigations involve substantial amounts of radiation, with well-recognized carcinogenic risks. Because patient safety is paramount, radiation exposure should be minimized. This may be possible by standardizing radiation exposure throughout the United Kingdom by implementing national guidelines and considering other imaging modalities for follow-up.

Objective: This study determined the rate, extent, and clinical significance of neck dilatation after endovascular aneurysm repair (EVAR).Methods: The study included 46 patients who underwent elective EVAR using bifurcated Zenith stent grafts (Cook, Bloomington, Ind) and had at least 48 months of clinical and radiographic follow-up. Computed tomography images were analyzed on a 3-dimensional workstation (TeraRecon, San Mateo, Calif). Neck diameter was measured 10 mm below the most inferior renal artery in planes orthogonal to the aorta. Nominal stent graft diameter was obtained from implantation records.Results: Median follow-up was 59 months (range, 48-120 months). Neck dilation occurred in all 46 patients. The rate of neck dilation was greatest at early follow-up intervals. At 48 months, median neck dilation was 5.3 mm (range, 2.3-9.8 mm). The extent of neck dilation at 48 months correlated with percentage of stent graft oversizing (Spearman ρ = 0.61, P < .001). No type I endoleak or migration >5 mm occurred.Conclusions: After EVAR with the Zenith stent graft, the neck dilates until its diameter approximates the diameter of the stent graft. Neck dilation was not associated with type I endoleak or migration of the stent graft.

Objective: Claudication is the most common manifestation of peripheral arterial disease, producing significant ambulatory compromise. Our study evaluated patients with bilateral lower limb claudication and characterized their gait abnormality based on advanced biomechanical analysis using joint torques and powers.Methods: Twenty patients with bilateral claudication (10 with isolated aortoiliac disease and 10 with combined aortoiliac and femoropopliteal disease) and 16 matched controls ambulated on a walkway while 3-dimensional biomechanical data were collected. Patients walked before and after onset of claudication pain. Joint torques and powers at early, mid, and late stance for the hip, knee, and ankle joints were calculated for claudicating patients before and after the onset of claudication pain and were compared to controls.Results: Claudicating patients exhibited significantly reduced hip and knee power at early stance (weight-acceptance phase) due to decreased torques produced by the hip and knee extensors. In mid stance (single-limb support phase), patients had significantly reduced knee and hip power due to the decreased torques produced by the knee extensors and the hip flexors. In late stance (propulsion phase), reduced propulsion was noted with significant reduction in ankle plantar flexor torques and power. These differences were present before and after the onset of pain, with certain parameters worsening in association with pain.Conclusions: The gait of claudication is characterized by failure of specific and identifiable muscle groups needed to perform normal walking (weight acceptance, single-limb support, and propulsion). Parameters of gait are abnormal with the first steps taken, in the absence of pain, and certain of these parameters worsen after the onset of claudication pain.

Background: Most outcomes registries use a large number of variables to control for differences in patients. We sought to determine whether fewer variables could be used for risk adjustment without compromising hospital quality comparisons.Methods: We used prospective, clinical data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) for five commonly performed inpatient vascular procedures (N = 24,744). For each of the five operations, we compared the ability of two parsimonious models (an intermediate model, using the top five variables for each procedure and a limited model using the top 2 variables from each procedure) and the full model (up to 42 variables) to predict the risk of mortality and morbidity at the patient and hospital level.Results: The parsimonious model was similar to the full model in all comparisons. For the five procedures, the intermediate, limited, and full models all had very similar discrimination at the patient-level (C indices of 0.87 vs 0.85 vs 0.87 for mortality and 0.77 vs 0.75 vs 0.77 for morbidity), and similar calibration, as assessed with the Hosmer-Lemeshow test. In evaluating hospital-level morbidity and mortality rates, the correlations between the parsimonious and full models were very high for both mortality (>0.97 across operations) and morbidity (>0.97 across operations).Conclusions: Hospital quality comparisons for vascular surgery can be adequately risk-adjusted using a small number of important variables. Reducing the number of variables collected will significantly decrease the burden of data collection for hospitals choosing to participate in the vascular module of the ACS-NSQIP.

Objective: Although secondary lymphedema is a common complication after surgical and radiation therapy for cancer, the treatment options for lymphedema remain limited and largely ineffective. We thus studied the effect of extracorporeal shock wave therapy on promoting lymphangiogenesis and improving secondary lymphedema.Methods: A rabbit ear model of lymphedema was created by disruption of lymphatic vessels. Two weeks after surgery, the lymphedematous ear was treated with or without low-energy shock waves (0.09 mJ/mm2, 200 shots), three times per week for 4 weeks.Results: Western blot analysis showed that the expression of vascular endothelial growth factor (VEGF)-C (1.23-fold, P < .05) and VEGF receptor 3 (VEGFR3; 1.53-fold, P < .05) was significantly increased in the ears treated with shock wave than in the untreated lymphedematous ears. Compared with the control group, shock wave treatment led to a significant decrease in the thickness of lymphedematous ears (3.80 ± 0.25 mm vs 4.54 ± 0.18 mm, P < .05). Immunohistochemistry for VEGFR3 showed the density of lymphatic vessels was significantly increased by shock wave treatment (P < .05).Conclusion: Extracorporeal shock wave therapy promotes lymphangiogenesis and ameliorates secondary lymphedema, suggesting that extracorporeal shock wave therapy may be a novel, feasible, effective, and noninvasive treatment for lymphedema.Clinical Relevance: Therapeutic options for lymphedema are currently limited to supportive treatment. Thus, it is desirable to develop a curative treatment for lymphedema. The findings of the present study suggest that extracorporeal shock wave therapy is effective in treating lymphedema. Further clinical trials are required to confirm the efficiency of this therapy.

Mycotic aneurysms represent a diagnostic and therapeutic challenge still lacking general recommendations for optimal therapy. So far, Listeria monocytogenes (L. monocytogenes) is very rarely reported to be the causative organism of mycotic aortic aneurysms. We report 2 cases of mycotic abdominal aortic aneurysms due to L. monocytogenes infection being treated by radical debridement, open in situ reconstruction with aorto-bi-iliac Dacron grafts, and long-term antibiotic therapy. Both patients recovered well from surgery. Interestingly, the long-time follow-up for the first patient 9 years after surgery was entirely uneventful. Open debridement in an in situ reconstruction with Dacron grafts followed by antibiotic therapy seems to be a suitable therapeutic regime for mycotic aneurysms due to L. monocytogenes.

“The transition between life and death should be gentle in the winter of life.”Rudolph Matas, Father of Vascular Surgery You are a member of the Ethics Committee at a moderately-sized private hospital. Dr D.E. Mure, a seasoned vascular surgeon, asks the Committee's advice. Dr Mure repaired an 80-year-old male's ruptured abdominal aortic aneurysm two weeks ago. The patient, a popular retired minister, remains in deep coma but has not been declared brain dead. Moreover, the multiple organ dysfunction score has gradually worsened so that survival is very unlikely. The patient's family feels fervently that he will survive to live a useful life again. Dr Mure discussed discontinuing life-sustaining treatment with the family last evening but suddenly could not continue. He explains that he recently watched the movie, You Don't Know Jack, an unvarnished biopic of Dr Jack Kevorkian, and felt he was about to do the same thing, namely, assist in a suicide. What should the Committee advise Dr Mure?

Vascular surgery has matured to the point that there exists robust bodies of literature exploring many of our therapies. However, this evidence is but one of the factors that dictate medical practice. Others include local patient demographics, the practical implications of healthcare delivery, and an individual surgeon's interpretation of this evidence, which can be somewhat subjective. As a result, there are numerous examples of vascular specialists' practice patterns differing depending on their geographic location. Recognizing this, the Editors of the Journal of Vascular Surgery and the European Journal of Vascular and Endovascular Surgery have developed a series of Trans-Atlantic Debates to explore these instances. The inaugural debate explores the controversial question of how best to manage asymptomatic carotid artery stenoses. Our debators, Peter Schneider and Ross Naylor, offer reasoned and passionate arguments to defend their differing approaches. We trust that this addition to our journals will prove enlightening and, perhaps, entertaining.

Dr Schneider and Prof Naylor have offered a spirited debate regarding the optimal approach to patients with significant asymptomatic carotid artery stenoses. Their arguments are clear, reasoned, passionate, and in direct opposition with each other. Both would agree that stroke in patients with asymptomatic stenoses is a relatively rare event, and, given its potentially devastating consequences, should be avoided. Further points of agreement are few and far between.

Emile F. Holman, who was the last Chief Resident to William Stewart Halsted at Johns Hopkins University, identified a number of contributions that Halsted made to vascular surgery. Holman had been a Stanford University undergraduate, class of 1911, and a Johns Hopkins Medical School graduate in 1918. He became the first full-time Professor and Chairman of the Department of Surgery at Stanford Medical School in San Francisco, California, in 1926. Stimulated in part by the teaching and writing of Halsted, Holman continued with an interest in vascular surgery and, particularly, the management of vascular injuries. His classic monograph in 1937 on the pathophysiology of arteriovenous fistulas is a landmark contribution in the 20th century in vascular trauma. This review, based in part on personal experiences, emphasizes the great value of mentorship and the legacy that can be passed on, as it has in the Halsted-Holman vascular trauma legacy, to continue to improve combined efforts in providing the best surgical management possible for those who have the misfortune to be injured.

This article reviews the use of cryopreserved homografts for aorto-iliac arterial reconstruction. When a prior prosthetic aortic bypass graft becomes infected, one treatment option includes graft excision with aortic ligation and extra-anatomic bypass of the lower extremities. CPT code 35907 is used to report excision of an infected abdominal graft. Axillo-bifemoral bypass with “other than vein” is described by CPT code 35654 (actually listed as “axillary-femoral-femoral” in the CPT manual). The lower-valued code is, of course, subject to the multiple procedure discount and cut by fifty percent if performed on the same date of service. If the bypass is done first and then the graft excision is performed days to weeks later, the second procedure will fall within a 90-day global period and require the −58 “staged procedure” modifier for appropriate reimbursement.

The authors discuss their experience with groin pseudoaneurysms after transluminal procedures. They identified higher level of d-dimer values in patients with a positive diagnosis.

Conclusion: Long-term mortality is high after endovascular repair of abdominal aortic aneurysm (AAA). In the setting of endovascular AAA repair, the Lee Index may be useful for stratifying short-term and long-term mortality in high-risk patients.

Conclusion: Applying JUPITER trial eligibility criteria, 21% of patients not eligible for lipid-lowering therapy by the guidelines proposed by the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) would be eligible for lipid-lowering therapy based on JUPITER trial eligibility.

Conclusions: Long-term survival after open and endovascular abdominal aortic aneurysm (AAA) repair is the same, but endovascular repair is more expensive and is associated with more reinterventions.

Conclusion: It is possible to simplify lipid assessment in vascular disease by measuring either total high-density lipoprotein (HDL) cholesterol (HDL-C) levels or apolipoproteins. It is not necessary to fast or measure triglyceride levels.

Conclusion: Mortality of open abdominal aortic aneurysm (AAA) repair that includes visceral or renal artery bypass is higher than for open AAA repair without visceral or renal artery bypass and depends on increasing age and the presence of renal or congestive heart failure.

Conclusion: Tadalafil is well tolerated and safe in patients with systemic sclerosis but lacks efficacy in comparison with placebo. Summary: The endothelial injury of systemic sclerosis is associated with decreased nitric oxide production (Kahaleh et al, Rheum Diseases Clin N Am 2008;34:57-71). Type V cyclic GMP phosphodiesterase (PDE-5) affects the tone of smooth muscle. An intracellular regulator of smooth muscle tone is cyclic nucleotide monophosphate, cGMP. Nitric oxide synthase produces nitric oxide. Through a complex pathway, nitric oxide facilitates conversion of GTP into cGMP. PDE-5 breaks down intracellular cGMP. Therefore, inhibition of PDE-5 results in increased availability of intracellular cGMP and results in vasodilatation. Tadalafil is a PDE-5 inhibitor effective in the use of male erectile dysfunction. However, PDE-5 inhibitors have also been suggested as beneficial in patients with severe Raynaud's syndrome (Fries R et al, Circulation 2005;119:2980-5). Tadalafil is an intriguing PDE-5 inhibitor in that it has a half-life of 17.5 hours and efficacy up to 36 hours. The pharmacokinetics of tadalafil are not affected by food or alcohol, age, diabetes, or moderate hepatic insufficiency. It therefore would seem an ideal drug for facilitating vasodilatation in patients with Raynaud's syndrome. This was a randomized, prospective, double-blind, placebo-controlled, crossover study comparing oral tadalafil with a fixed daily dose of 20 mg for 4 weeks vs placebo. The study was conducted in patients with Raynaud's syndrome secondary to systemic sclerosis. Thirty-nine completed the study. All patients fulfilled American College of Rheumatology classification criteria for systemic sclerosis. All were at least 18 years of age and had evidence of at least six Raynaud's attacks during the 2-week pretreatment period. Patients with unstable angina, congestive heart failure, or use of nitrites for angina pectoris or any other condition as well as those with significant central nervous system disease were excluded. Before enrollment, all patients discontinued any other type of vasodilator. Patients were evaluated for duration and frequency of Raynaud's attacks and Raynaud condition scores (RCS). At the end of the evaluation period, there were no significant statistical differences in RCS scores, frequency of Raynaud's attacks, or duration of Raynaud's attacks between the treatment and placebo groups.

Conclusion: Patients with atherosclerotic renal artery stenosis (RAS) presenting for percutaneous transluminal renal angioplasty have an increased risk of death after renal angioplasty. Renal artery revascularization results in improvement in heart failure control and a reduction in heart failure-related hospitalizations.