European Journal of Vascular and Endovascular Surgery

Nadia Vallejo, Julio A. Rodriguez-Lopez, Paniz Heidari, Grayson Wheatley, David Caparrelli, Venkatesh Ramaiah, Edward B. Diethrich Purpose: Some patients with aortic arch or descending thoracic aorta pathologies are not suited for open repair because of comorbidities that may increase their risk of procedural complications or death. Endovascular approaches may also be difficult when there are inadequate proximal landing zones in the aortic arch. We report our experience using rerouting techniques with bypass, stenting of the branches, or a combination of both to create a landing area in zones 0 and 1 of the aortic arch.

“These patients say they cannot afford to wait for research results because they will wind up in wheelchairs before the studies are done. Their only option, so far, has been a lifelong course of drugs with limited benefits and harsh side-effects. To some, balloon treatment seems no riskier than those drugs”Denise Grady, New York Times

The invited commentary of Mayer and Ziemann about our original article on venous angioplasty in chronic cerebrospinal venous insufficiency in multiple sclerosis patients (CCSVI-MS) raises several important questions in relation to the methodology of our study.

The invited commentary of Dr. Reekers discussing our original article on venous angioplasty in chronic cerebrospinal venous insufficiency in multiple sclerosis patients (CCSVI-MS) may be more suited to an opinion-based section of the journal rather than a section requiring academic standards to be met when writing commentary about a peer-reviewed article.

I read this manuscript with interest as this prospective, case-controlled pilot study represents a multi-specialty collaboration amongst vascular surgeons, interventionists, and neurologists that adds to our understanding of the implications of CCSVI in MS patients. The fundamental value of a pilot study is that it can be used to test the design for a larger-scale study and, in this case, gives us a glimpse into the potential qualitative measures and treatment outcomes that could be explored in MS patients with CCSVI. Zamboni’s study evaluates 15 patients with CCSVI associated with relapse remitting MS who underwent immediate vs. delayed (6 months) internal jugular and/or azygous venous angioplasty. Parameters evaluated were well beyond safety and feasibility, and include T1- and T2-weighted MRI assessment of changes in the number and volume of the demyelinated CNS lesions, percent brain volume changes, as well as clinical correlations with EDSS and MSFC. These are parameters that are well accepted by international MS and Neurology societies.

Charles J. Keith Jr, Marc A. Passman, Martin J. Carignan, Gaurav M. Parmar, Shardul B. Nagre, Mark A. Patterson, Steven M. Taylor, William D. Jordan Jr Background: Spinal cord ischemia (SCI) remains a significant concern in patients undergoing endovascular repair involving the thoracic aorta (thoracic endovascular aortic repair [TEVAR]). Perioperative lumbar spinal drainage has been widely practiced for open repair, but there is no consensus treatment protocol using lumbar drainage for SCI associated with TEVAR. This study analyzes the efficacy of an institutional protocol using selective lumbar drainage reserved for patients experiencing SCI following TEVAR.

We would like to thank Dr. Nordon for his interest in and remarks on our manuscript. We fully agree that the translation of proteomics-discovered biomarkers into clinically meaningful assays is difficult. However, our aim was to find differential protein expression related to aneurysm size and progression. These differentially expressed proteins could help to elucidate the mechanisms behind abdominal aortic aneurysm.

Abstract: Introduction: Kinking and endofibrosis of the iliac arteries are uncommon and poorly recognized conditions affecting young endurance athletes. Deformation or progressive stenosis of the iliac artery may reduce blood flow to the lower limb and adversely affect performance. The aim of this review was to examine the existing literature relating to these flow-limiting phenomena and identify a clear, unifying strategy for the assessment and management of affected patients.Methods: A systematic review of the literature was performed. A comprehensive search was carried out using Medline, Embase and The Cochrane Database to identify relevant articles published between 1950 and 2011 (last search date 05/08/2011). This search (and additional bibliography review) identified 413 articles, of which 367 were excluded. 46 articles were then studied in detail. Methodological quality of studies was assessed according to Scottish Intercollegiate Guideline Network criteria.Results: Focussed history and examination can successfully identify nearly 80% of patients with iliac flow limitation. However, both provocative exercise tests and detailed imaging are also necessary to identify those in need of intervention and establish most appropriate treatment. Provocative exercise tests and duplex imaging can then be used to confirm flow limitation before detailed assessment of abnormal anatomy with MRA and DSA. These multiple imaging modalities are necessary to identify those most likely to benefit from surgery and clarify whether each patient should undergo arterial release, vessel shortening, endofibrosectomy or interposition grafting.Conclusion: We present a systematic review of the literature together with a proposed algorithm for diagnosis and management of these iliac flow limitations in endurance athletes.

Abstract: Background: Between 1951 and 1995 there was a steady increase in age-standardised deaths from all aortic aneurysms in men, from 2 to 56 per 100,000 population in England & Wales, supporting an increase in incidence. More recently, evidence from Sweden and elsewhere suggests that now the incidence of abdominal aortic aneurysm (AAA) may be declining.Methods: National statistics for hospital admissions and deaths from AAA, after population age-standardisation, were used to investigate current trends in England & Wales and Scotland.Results: Between 1997 and 2009 there has been a reduction in age-adjusted mortality from AAA from 40.4 to 25.7 per 100,000 population for England & Wales and from 30.1 to 20.8 per 100,000 population in Scotland. The decrease in mortality was more marked for men than women. Mortality decreased more than 2-fold in those <75 years versus 25% only in those >75 years. During this same time period the elective hospital admissions for AAA repair have only increased in the population >75 years.Conclusions: These data suggest that the age at which clinically-relevant aneurysms present has increased by 5–10 years and that incidence of clinically-relevant AAA in men in England & Wales and Scotland is declining rapidly. The reasons for this are unclear.

Abstract: Objectives: Renal failure following abdominal aortic aneurysm (AAA) repair is a common and significant complication. The objective of this study was to identify risk factors for renal failure following open elective AAA repair.Design: A retrospective analysis of prospectively collected multi-centre data.Materials: Consecutive data on patients undergoing open elective AAA repair were collected between January 2000 and December 2010. Patients with pre-operative serum creatinine >200 μmol/L were excluded.Methods: Renal failure was reported by clinicians and included all patients requiring post-operative renal-replacement therapy. Univariate and multivariate analyses were used to identify renal failure risk factors. A simplified clinical risk score was developed.Results: Post-operative renal failure occurred in 140 (6.0%) of 2347 patients and was associated with age >75 (OR = 1.58, 95%CI 1.11–2.26), symptomatic AAA (OR = 1.77, 95%CI 1.24–2.52), supra/juxta renal AAA (OR = 2.17, 95%CI 1.32–3.57) pre-operative serum creatinine >150 (OR = 2.75, 95%CI 1.69–4.50), treated hypertension (OR = 1.87, 95%CI 1.28–2.74), and respiratory disease (OR = 2.08, 95%CI 1.45–2.97). Patients with post-operative renal failure had significantly higher 30-day mortality (35.0% vs. 4.3%, p < 0.001).Conclusions: Renal failure following open elective AAA repair was associated with an increased risk of mortality. Risk factors for post-operative renal failure were identified and a simple clinical risk score developed to facilitate focussed care strategies for high-risk patients.

Nitinol and titanium vascular anastomotic clips were introduced in access surgery more than a decade ago. Compared to sutured anastomoses, clipped ones are performed faster, with fewer bleeding and infectious complications, while improved maturation, and better primary, and secondary patency of autogenous arteriovenous fistulas (AVFs) and prosthetic grafts have been reported in most studies. Improved outcomes might be the result of reduced neointimal hyperplasia (NIH) as shown in AVF and non-AVF models, improved anastomotic compliance, preservation of endothelial function, minimized endothelial/vessel wall trauma and reduced thrombosis potential, and perhaps bias due to slight differences in technique. Graft flow in clipped and sewn anastomoses has been reported to be the same.

In their paper “Differential expression in serum of abdominal aortic aneurysm patients – A proteomic approach”, Pulinx et al. mined the proteome of patients with AAAs in search of novel biomarkers. They report elevated factor XII and α-1 antitrypsin levels in the serum of patients with progressive aneurysms, but found these proteins to have little ability to predict aneurysm progression above the established marker, AAA diameter.

We would like to commend you for your work and we were delighted to read your five-year comparison of CEUS and CTA for EVAR surveillance. This is to our knowledge the largest series to compare these two modalities and we are keen advocates of CEUS for EVAR surveillance also having achieved similar results to you in our department. Currently we are using three techniques for our surveillance, we are comparing CTA with duplex ultrasound and also CEUS for selective cases.

Abstract: Background: AortaScan AMI 9700 is a portable 3D ultrasound device that automatically measures the maximum diameter of the abdominal aorta without the need for a trained sonographer. It is designed to rapidly diagnose or exclude an AAA and may have particular use in screening programs. Our objective was to determine its accuracy to detect AAA.Methods: Subjects from our AAA screening and surveillance programs were examined. The aorta was scanned using the AortaScan and computed tomography (CT).Results: Ninety-one subjects underwent imaging (44 AAA on conventional ultrasound surveillance and 47 controls). The largest measurement obtained by AortaScan was compared against the CT-aortic measurement. The mean aortic diameter was 2.8 cm. The CT scan confirmed the diagnosis of AAA in 43 subjects. There was one false positive measurement on conventional ultrasound. AortaScan missed the diagnosis of AAA in eight subjects. There were thirteen false positive measurements. The sensitivity, specificity, positive and negative predictive values were 81%, 72%, 72% and 81% respectively.Conclusion: A device to detect AAA without the need for a trained operator would have potential in a community-based screening programme. The AortaScan, however, lacks adequate sensitivity and significant technical improvement is necessary before it could be considered a replacement for trained screening personnel.