I would like to congratulate the authors for their attempt to prove a long suspected fallout effect of the chronic cerebrospinal venous insufficiency (CCSVI) on the development/progress of multiple sclerosis (MS).

In the days following the earthquake in Haiti, many of us wondered how we could help. When a group from our hospital coordinated a trip, my chairman, Dr. Walter McCarthy, and I called to volunteer.

We have read with interest the case reports by Maged et al describing different cases of cystic adventitial disease (CAD). We came to realize that we are already aware of the role of magnetic resonance imaging (MRI) in an early specific preoperative diagnosis with regard to CAD. Maged propagates the use of MRI, for it best demonstrates the presence of connections between adventitial cysts and the adjacent joint. This is important to know, because total resection of the cysts, including connections to the joint, prevents recurrence.

We read with interest the letter to the editor regarding our article “High spatial resolution magnetic resonance imaging of cystic adventitial disease of the popliteal artery.” As the title implies, we reported the (never before published) use of a novel magnetic resonance (MR) technique, high spatial resolution magnetic resonance imaging (MRI) in three patients with cystic adventitial disease (CAD).

We have read with great interest the article of Norman et al in the Journal of Vascular Surgery dealing with serum carboxymethyllysine (CML) concentrations in diabetic men with abdominal aortic aneurysms. CML belongs to the group of advanced glycation end products (AGEs) and has been associated with the development of atherosclerosis. AGE concentrations are increased in diabetes and are related to arterial stiffness. Tissue accumulation of AGEs leads to cross-linking of proteins, for example, within the vessel wall, which may lead to increased arterial stiffness. Norman et al hypothesize that AGEs may be partly responsible for the observed inverse association between abdominal aortic aneurysm and diabetes. Indeed, they observed lower serum CML concentration in diabetic men with AAA than in those without. Several questions remain after reading this article, however.

The points made in the letter do not contradict our data. Advanced glycation end products (AGEs) are a heterogeneous group. Non-carboxymethyllysine (CML) AGEs may influence the development of abdominal aortic aneurysms (AAAs), and assessing concentrations of cross-linking AGEs like pentosidine will be important. We did not claim that our study provided conclusive evidence—merely that the data suggested that accelerated advanced glycation might explain the inverse association between diabetes and AAA. We had also acknowledged that other markers of the glycation pathway would need to be examined in future studies.

DePalma et al described interactions of serum ferritin with statin use in a substudy of the iron (Fe) and atherosclerosis study (FeAST). At baseline, 53 participants on statins had slightly lower mean entry-level ferritin values (1l4.06 ng/mL) vs the 47 off statins (127.62 ng/mL). Longitudinal analysis of follow-up data, after adjusting for the phlebotomy treatment effect, showed that statin use was associated with significantly lower ferritin levels (–29.78 ng/mL; Cohen effect size, −0.47 [tdf, 134 = 2.33, P = .02]).

Dr Sullivan's insights and Dr Zacharski's energetic implementation of Veteran's Affairs Cooperative Study Trial 410 stimulated our biomarker substudy in the Sierra Nevada Health Care cohort of patients with symptomatic peripheral arterial disease. Dr Sullivan now suggests mechanisms to account for interactions of iron and statins associated with interleukin-6 (IL-6) elevations which we found to be related to iron levels in clinically stable participants. We might conjecture that iron overload itself stimulates inflammatory responses and leukocyte activity for which IL-6 is the biomarker. The statin findings resulted from increasing use of these agents during the 6-year iron (Fe) and atherosclerosis study (FeAST) trial.

In the March 2010 issue of the Journal of Vascular Surgery, Dr Thrasivoulos Tzellos was erroneously left off of the author byline for the following article. The correct author list including Dr. Tzellos is as follows:

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The case of a 20-year-old woman with a carotid body tumor of Shamblin class III is reported. Ten hours after preoperative direct intralesional embolization with 20 mL Onyx (ethylene-vinyl alcohol copolymer; Micro Therapeutics, Irvine, Calif), the patient showed symptoms of Horner syndrome and deficits of the hypoglossal and glossopharyngeal nerves. Intraoperative examination 12 hours after Onyx embolization revealed a massive swelling of the hypoglossal and glossopharyngeal nerves. The patient's tongue motility and glossopharyngeal function improved after surgery, but Horner syndrome was still present. Owing to the delayed occurrence of these adverse effects, the optimal time of surgical intervention after Onyx embolization should be discussed and perhaps expedited.

Background: Great saphenous vein (GSV) incompetence is the most common cause of superficial venous insufficiency. Radiofrequency catheter ablation (RFA) is superior to conventional ligation and stripping, and endovenous laser treatment (EVL) has emerged as an effective alternative to RFA. This randomized study evaluated RFA and EVL for superficial venous insufficiency due to GSV incompetence and compared early and 1-year results.Methods: Between June 2006 and May 2008, patients with symptomatic primary venous insufficiency due to GSV incompetence were randomized to RFA or EVL. Patients with bilateral disease were randomized for treatment of the first leg and received the alternative method on the other. Pretreatment examination included a leg assessment using the Venous Clinical Severity Score (VCSS) and CEAP classification. Patients completed the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2). RFA was performed with the ClosurePlus system (VNUS Medical Technologies, Sunnyvale, Calif). EVL was performed with the EVLT system (AngioDynamics Inc, Queensbury, NY). Early (1-week and 1-month) postoperative results of pain, bruising, erythema, and hematoma were recorded. Duplex ultrasound (DU) imaging was used at 1 week and 1 year to evaluate vein status. VCSS scores and CEAP clinical class were recorded at each postoperative visit, and quality of life (QOL) using CIVIQ2 was assessed at 1 month and 1 year.Results: The study enrolled 118 patients (141 limbs): 46 (39%) were randomized to RFA and 48 (40%) to EVL, and 24 (20%) had bilateral GSV incompetence. At 1 week, one patient in the RFA group had an open GSV and was deemed a failure. More bruising occurred in the EVL group (P = .01) at 1 week, but at 1 month, there was no difference in bruising between groups. At 1 year, DU imaging showed evidence of recanalization with reflux in 11 RFA and 2 EVL patients (P = .002). The mean VCSS score change from baseline to 1 week postprocedure was higher for RFA than EVL (P = .002), but there was no difference between groups at 1 month (P = .07) and 1 year (P = .9). Overall QOL mean score improved over time for all patients (P < .001). CEAP clinical class scores of ≥3 were recorded in 21 RFA (44%) and 24 EVL patients (44%) pretreatment, but at 1-year, 9 RFA (19%) and 12 EVL patients (24%) had scores of ≥3 (P < .001). This represented a significant improvement in all patients compared with baseline.Conclusion: Both methods of endovenous ablation effectively reduce symptoms of superficial venous insufficiency. EVL is associated with greater bruising and discomfort in the perioperative period but may provide a more secure closure over the long-term than RFA.

Background: Abdominal aortic aneurysm (AAA) disease is an insidious condition with an 85% chance of death after rupture. Ultrasound screening can reduce mortality, but its use is advocated only for a limited subset of the population at risk.Methods: We used data from a retrospective cohort of 3.1 million patients who completed a medical and lifestyle questionnaire and were evaluated by ultrasound imaging for the presence of AAA by Life Line Screening in 2003 to 2008. Risk factors associated with AAA were identified using multivariable logistic regression analysis.Results: We observed a positive association with increasing years of smoking and cigarettes smoked and a negative association with smoking cessation. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. Blacks, Hispanics, and Asians had lower risk of AAA than whites and Native Americans. Well-known risk factors were reaffirmed, including male gender, age, family history, and cardiovascular disease. A predictive scoring system was created that identifies aneurysms more efficiently than current criteria and includes women, nonsmokers, and individuals aged <65 years. Using this model on national statistics of risk factors prevalence, we estimated 1.1 million AAAs in the United States, of which 569,000 are among women, nonsmokers, and individuals aged <65 years.Conclusions: Smoking cessation and a healthy lifestyle are associated with lower risk of AAA. We estimated that about half of the patients with AAA disease are not eligible for screening under current guidelines. We have created a high-yield screening algorithm that expands the target population for screening by including at-risk individuals not identified with existing screening criteria.

Objective: The utilization of endovascular abdominal aortic aneurysm repair (EVAR) in suitable patients has resulted in decreased perioperative morbidity and mortality. Octogenarians as a subgroup have been more readily offered EVAR, as it is less invasive, and therefore presumably better tolerated than conventional open aortic repair. The purpose of this study is to investigate periprocedural and late EVAR outcomes in octogenarians compared with patients less than 80 years of age.Methods: From January 2003 to May 2008, 322 patients underwent EVAR. A total of 117 octogenarians were compared with 205 patients less than 80 years of age. A retrospective review of the demographic data, aneurysm details, perioperative morbidity, mortality, and late outcomes were analyzed.Results: Octogenarians were significantly more likely to have a history of diabetes mellitus (51% vs 23%; P < .001), coronary artery disease (45% vs 32%; P = .0165), chronic obstructive pulmonary disease (44% vs 30%; P = .0113), and renal insufficiency (57% vs 31%; P < .0001). There were no significant differences in the rates of perioperative myocardial infarction, stroke, death, intestinal, or arterial ischemic complications between the two groups. Octogenarians had a significant higher rate of pulmonary complications (5.1% vs 1%; P < .03) and access-site hematomas (12% vs 2.4%; P = .001) than younger patients. When all significant perioperative morbidity was combined, octogenarians were twice as likely to develop complications following EVAR than younger patients (27.4% vs 11.7%; P = .001). At 5-year follow-up, younger patients were twice as likely to develop type II endoleaks.Conclusions: EVAR can be performed safely and effectively in octogenarians, and the incidence of major complications including myocardial infarction, stroke, and death is unchanged compared with younger patients. However, there is a significantly increased rate of access-site hematomas, pulmonary, and perioperative complications in octogenarians as a whole. Our findings suggest EVAR remains a suitable form of therapy in the elderly group provided there is an appropriate preoperative evaluation and perioperative monitoring following repair.

Dr Thomas Forbes (London, Ontario, Canada). With the absence of long-term outcomes in octogenarians, the authors set out to investigate periprocedural and long-term outcomes in these patients compared to younger patients. Over a recent 5-year period, they treated 320 patients, a third of which were over 80 years of age. Not only were these patients older, but they were also sicker, with higher degrees of coronary disease, diabetes, hypertension, COPD, and renal dysfunction.

Objectives: Octogenarians and even patients over 70 years old have unexplained poor outcomes with carotid angioplasty and stenting (CAS). We sought to evaluate whether older patients may have compromised intracranial collaterals and cerebral reserve and be intolerant to otherwise clinically silent emboli generated during CAS.Methods: One thousand twenty-four cerebral blood flow (CBF) studies performed between 1991 and 2001 with stable xenon computed tomography scans (Xe/CT) were reviewed. CBF was measured before and after 1 gm intravenous acetazolamide (ACZ), a cerebral vasodilator. The normal response to ACZ is an increase in CBF. In areas of significant compromise of cerebral reserve (CR), CBF drops, representing a “steal” phenomenon. CBF changes were categorized as normal or abnormal and correlated with age, gender, cerebral symptoms, and with intracranial, carotid, or vertebral artery disease. Logistic regression was used to determine the effect of age on CR in the entire group and a subgroup of 179 patients with significant carotid stenosis of >50%.Results: Nine hundred sixteen studies were suitable for analysis. Carotid occlusion was predictive of decreased reserve (OR, 3.9; P = .03) regardless of age. There was also a trend toward lower reserve with severe carotid stenosis >70% (OR, 3) and in women (OR, 1.8; P = .08). Age ≥70 had no effect on reserve in the overall heterogeneous population with and without carotid disease and neither did a history of stroke, carotid, or intracranial stenosis. However, in 179 patients with significant carotid stenosis, age ≥70 was predictive of poor reserve (OR, 2.7; P = .03) and so was the presence of peripheral vascular disease (OR, 3.7; P = .03). A trend toward decreased reserve was also seen in women (OR, 2.3; P = .08).Conclusions: Age ≥70 is associated with poor cerebral reserve in patients with significant carotid stenosis as measured by CBF response to an ACZ challenge. Thus, patients ≥70 may be more sensitive to minor cerebral emboli, which may be one factor explaining their higher risk of stroke during CAS.