Segmental arterial mediolysis after fenestrated endovascular abdominal aortic aneurysm repair-A rare complication.

Segmental arterial mediolysis (SAM) is a rare, noninflammatory, nonatherosclerotic condition that occurs commonly in mesenteric vessels. There are no known predisposing risk factors to the development of SAM. We present a case of a 67-year-old woman who presented with abdominal pain 2 days following discharge after an elective endovascular abdominal aortic intervention. Repeat imaging 2 days after readmission showed the presence of multiple new aneurysms involving the mesenteric vasculature. She underwent attempted endovascular embolization of the largest aneurysm. The postmortem and histopathologic examinations confirmed the diagnosis of SAM.

Carnosine as a potential therapeutic for the management of peripheral vascular disease.

AIMS: To evaluate the potential role of carnosine in the management of peripheral vascular disease. DATA SYNTHESIS: Peripheral vascular disease is growing in its burden and impact; however it is currently under researched, and there are a lack of strong, non-invasive therapeutic options for the clinicians. Carnosine is a dipeptide stored particularly in muscle and brain tissue, which exhibits a wide range of physiological activities, which may be beneficial as an adjunct treatment for peripheral vascular disease. Carnosine's strong anti-inflammatory, antioxidant and antiglycating actions may aid in the prevention of plaque formation, through protective actions on the vascular endothelium, and the inhibition of foam cells. Carnosine may also improve angiogenesis, exercise performance and vasodilatory response, while protecting from ischemic tissue injury. CONCLUSIONS: Carnosine may have a role as an adjunct treatment for peripheral vascular disease alongside typical exercise and surgical interventions, and may be used in high risk individuals to aid in the prevention of atherogenesis. CLINICAL RECOMMENDATION: This review identifies a beneficial role for carnosine supplementation in the management of patients with peripheral vascular disease, in conjunction with exercise and revascularization. Carnosine as a supplement is safe, and associated with a host of beneficial effects in peripheral vascular disease and its key risk factors.

Pseudoendoleak: A post-endovascular aortic repair ultrasound surveillance pitfall - Single institution case series.

INTRODUCTION: In the context of increasingly common endovascular treatment for abdominal aortic aneurysms, endoleak is a relatively common complication of (abdominal) EVAR, and ongoing multimodality surveillance programs are recommended by expert bodies including the Society for Vascular Surgery (SVS). We describe the colour doppler ultrasound (CDUS) finding defined as pseudoendoleak that may be misinterpreted as significant endoleak and may be resolved through the use of contrast-enhanced ultrasound (CEUS). METHODS: Retrospective review of cases at our institution identified five cases where apparent endoleak on CDUS was not evident on CEUS, performed immediately following CDUS. RESULTS: Each of these five cases demonstrated interval increase in sac size at varying intervals post-EVAR, and in 4 out of 5 cases, no endoleak was demonstrated on multiple other modalities, at multiple time points. One case demonstrated an isolated type 2 endoleak at one time point, a finding that could not be reproduced. In each case, index-positive CDUS is thought to represent agitated fluid within the excluded sac that is not in continuity with the arterial blood pool as evidenced by the absence of CEUS enhancement. CONCLUSIONS: In cases of positive post-EVAR CDUS, CEUS is an effective tool to exclude the presence of pseudoendoleak and thus avoid further and potentially invasive diagnostic modalities in an elderly and comorbid cohort.

Role of endovenous laser therapy in large and very large diameter great saphenous veins.

BACKGROUND: The literature suggests that endovenous laser is less efficacious in great saphenous veins (GSVs) with a diameter of greater than 1 cm. This paper describes the efficacy of endovenous laser therapy (EVLT) in ablating GSV with a diameter greater than 1.0 cm. METHODS: Retrospective review of consecutive patients undergoing GSV EVLT between 15 November 2012 and 25 July 2013 was performed. GSV with a maximum diameter of ≥1.0 cm were defined as large, those with a maximum diameter of ≥2.0 cm were defined as very large. RESULTS: A total of 38 ablations were reviewed; two patients had bilateral GSV vein ablations. All underwent a 6-week post-procedural duplex. There were 20 ablations on veins >1 cm and 4 ablations on veins ≥2.0 cm. Median GSV length was 21.5 cm (16.5 cm for <1 cm, 24.5 cm for 1-2 cm and 24.5 cm for >2 cm). When correcting for length of vein treated, the energy deposited was stable for all patients at 80 J/cm. Tumescent volumes per centimetre were 3.7 mL/cm for veins <1.0 cm and 4.6 mL/cm for veins >1.0 cm. Successful ablation was achieved in 100% of veins independent of size. CONCLUSION: Ablation rates for large and very large GSVs in our series do not differ from the cohort of patients with GSV < 1.0 cm and from published results for GSVs < 1.0 cm. This supports the use of EVLT for venous insufficiency in the larger diameter GSV typically found in patients on public hospital waiting lists.

Complications and great escapes: equipment and techniques.

All endovascular procedures have the potential for complications. The primary aims should always be avoidance of preventable complications and to minimize the impact of any complication. The core principles of an effective preventive strategy are: involving the interventional and clinical teams in a clear outline of the procedure and its potential adverse outcomes; ensuring an adequate inventory of required and backup equipment; the use of "time-out" to minimize wrong patient/wrong side adverse events; and an active audit program to identify areas of improvement. In the event of an adverse outcome there are many strategies that can be employed to rectify the situation or minimize the iatrogenic injury. This article provides a case-based discussion highlighting some of these techniques and how they can be used in a clinical setting.

Streptococcus pyogenes aortic aneurysm infection: forgotten but not gone.

Historically, Streptococcus pyogenes was a common cause of endocarditis and infected aortic aneurysm. Today, endovascular infections due to this organism have become exceedingly rare. We report the first case of aortic aneurysm infection due to S. pyogenes treated with initial endoluminal repair, review previous reports and discuss current treatment options.

Outcomes of infective aneurysm repairs in the New Zealand thoracic stent database.

BACKGROUND: Infective thoracic aneurysms are rare and have a poor prognosis. In the past, these have been managed surgically with adjunctive antibiotic therapy. Endoluminal repair is a relatively new treatment option which may be associated with lower morbidity and mortality. METHODS: The New Zealand Thoracic Aorta Stent graft registry was interrogated between December 2001 and September 2009, selecting all patients with endoluminal repair of infective thoracic aortic aneurysms. RESULTS: Out of 184 patients on the database, four (2.2%) patients (male = 3, median age = 72) underwent endoluminal repair of an infective thoracic aortic aneurysm. The aneurysm was successfully excluded at the time of the procedure in all patients. There was a low incidence of post-procedural complications including atrial fibrillation (n = 1), pneumonia with haemoptysis (n = 1), urinary retention (n = 1) and access site seroma (n = 1). Time to discharge was mean of 26.5 days, median 22.5 days (8­53 days). One of the four patients is still alive and well at the time of reporting. Of the remaining three patients, mean survival is 486 days, median 374 days (336­748 days). CONCLUSIONS: Endoluminal repair is a treatment option for infective thoracic aneurysms, but the durability is unknown. Due to the rareness of the condition, a randomized clinical trial is unlikely to succeed. National registries such as the New Zealand Thoracic Aortic Stent provide useful information regarding this.

Cyanoacrylate embolization of endoleaks after abdominal aortic aneurysm repair.

INTRODUCTION: Type II endoleaks occur in up to a fifth of endoluminal repairs for abdominal aortic aneurysms and are commonly treated when aortic sac expansion can be demonstrated. Technical failure is common when catheter-guided particulates or coil embolic agents are used. Presented here is a feasibility study using catheter-directed N-butyl-2-cyanoacrylate (Histoacryl, Braun, Tuttlingen, Germany) embolotherapy. METHOD: A retrospective review of the case notes of patients undergoing embolization procedures for type II endoleaks with expanding sacs was performed from this centre's cohort of endoluminal aortic repair patients under surveillance. Data on patients with type II endoleaks who were treated with either or both cyanoacrylate and coil embolization were extracted. The outcomes were then compared. RESULTS: In total, five cases were identified, and four of these cases had both coil and glue embolization. Technical success was defined as endoleak closure proven on follow-up computed tomographic imaging. Technical success was achieved in all four patients treated with intra-sac cyanoacrylate. One case treated initially with coil embolization was successful. All patients had a computed tomographic scan at 3 months. One minor complication occurred that resolved without treatment. DISCUSSION: Type II endoleaks after EVAR with expanding sacs require treatment. Percutaneous catheter-directed cyanoacrylate embolization offers an alternative to coil or particulate embolization and, in this series, was found to be more likely to result in endoleak closure.

Informed consent for vascular intervention: completing one audit loop.

AIM: To reaudit documentation of the process of informed consent in patients undergoing vascular surgical and vascular radiological procedures. METHOD: A retrospective audit of randomly selected elective vascular radiological and surgical admissions from October 2005-2006 was undertaken to assess the impact of a previous audit on the documentation of the consent process carried out in 2005. Outpatient clinic letters, handwritten entries in the patients' admission notes, and consent forms were scrutinised and data collated on which doctors took consent, when consent was obtained, what details of the consent process were documented, and whether additional information was made available to patients. RESULTS: 99 sets of notes were reviewed (surgical n=50, radiological n=49). For patients undergoing vascular surgery, the consent form was signed by a consultant in 16 (32%) cases compared to 2 (4%) in the previous audit (p=0.013: Chi-squared). Significantly more vascular radiological consent forms were signed by a consultant (43) compared with surgical consent forms (16) (p<0.001; Chi-squared). Documentation that the risks of surgery had been discussed with the patient was present in 31 (62%) surgical notes and in 20 cases such discussions were documented in letters from clinics. For radiological consent documentation, 34 (69.4%) patient notes recorded discussions regarding procedural risk. Twenty-two (44.9%) of the vascular radiological patients had such risks documented in their outpatient notes by a vascular surgeon compared with 1 (2%) (p <0.001; Chi-squared) in the previous audit. Additional written information was given to 7(14%) of the vascular surgical patients which was similar to the previous audit. No additional information was given to patients who underwent vascular radiological procedures. CONCLUSIONS: Significant improvements have been made since the previous audit with more surgical consultants signing the consent forms and increased documentation of the nature of radiological procedures and risks discussed in outpatient clinics. From the current audit, provision of additional written information (patient information sheets) was an area identified for future improvement.

Endovascular repair of mycotic aortic aneurysms.

The management of mycotic aneurysms is difficult, with high morbidity and mortality. Traditional open operative approaches include removal of infected material with either extra-anatomic reconstruction or in situ graft repair. Since the advent of endovascular aneurysm repair (EVAR) in the early 1990s, its use in the treatment of aneurysm disease has increased due to proven decrease in 30-day mortality. There have been few case studies reporting the use of EVAR for infected aneurysms. We describe two cases of mycotic aneurysm of the abdominal aorta that were successfully managed with EVAR.

Treatment delays for patients exiting an aortic aneurysm surveillance programme.

BACKGROUND: We have previously reported abdominal aortic aneurysm (AAA)-related mortality in patients who have completed surveillance. This study investigates the journey time of patients who exited the AAA surveillance programme at Christchurch Hospital and underwent elective repair to determine the factors contributing to the interval between completing surveillance and undergoing surgical repair. METHODS: A retrospective review of patient notes was carried out for 25 patients who underwent elective repair of their AAA after exiting the surveillance programme between November 2000 and September 2005. RESULTS: The median time interval between exiting the programme and undergoing repair for patients fit for repair was 6 months. During this waiting period, there were two aneurysm-related deaths. Analysis of the patient journeys showed that those with significant comorbidity, that is, patients who required additional investigation by other clinicians (n = 7), had a median time to repair of 35 weeks. This was substantially increased compared with a median time of 22.5 weeks to repair for the rest (n = 18). CONCLUSION: At our institution the median time for completion of surveillance to repair was 6 months. An AAA with a diameter of 55 mm has an expected risk of rupture of 5%, with mortality approaching 90%. In our series, mortality was 4.9% (two patients died while awaiting repair), consistent with expected figures. Factors contributing to this delay of 6 months to repair were identified. Modifications to this journey are suggested to improve the time interval and therefore hopefully reduce the aneurysm-related mortality in this group.

Computed tomography arteriography to assess greater saphenous vein as a conduit for peripheral bypass.

BACKGROUND: To determine whether computed tomography arteriography of the lower extremities (64-slice volume computed tomography (CT)), used in delineating the arterial tree in peripheral vascular disease, is useful in assessing suitability of greater saphenous vein as a vascular conduit for peripheral bypass grafting for limb-threatening lower limb ischaemia. A search of published works in August 2005 showed no similar study has been published. METHODS: A prospective study of nine consecutive patients who had undergone lower limb CT arteriography and long saphenous vein colour duplex ultrasound (U/S) were studied. RESULTS: Good concordance between colour duplex U/S and CT arteriography was obtained. CONCLUSION: Computed tomography images of the long saphenous vein as a part of arterial lower limb CT arteriography correlate well with preoperative conduit assessment colour duplex U/S findings of the long saphenous vein.

Abdominal aortic aneurysm surveillance: application of the UK Small Aneurysm Trial to a New Zealand tertiary hospital.

AIMS: We present 5-year results of an abdominal aortic aneurysm surveillance programme at Christchurch Hospital, based on the UK Small Aneurysm Trial. METHOD: Patients with infrarenal abdominal aortic aneurysms between 30 and 55 mm were placed in an ultrasound-based surveillance programme with an intention to treat when their aneurysms reached the Vascular Service determined threshold, when the AAA became symptomatic, or when rapid AAA growth was demonstrated. Patients were divided into three groups: Group 1, those currently under or those who had completed surveillance (n=198); Group 2, those excluded from surveillance and therefore treatment due to unsuitability for open surgical or endoluminal exclusion who had not completed surveillance (n=18); and Group 3, those who declined surgery on completion of surveillance (n=5). We looked at the number of aneurysm-related deaths in these groups and examined any issues that arose during or upon completion of surveillance. RESULTS: There were five aneurysm-related deaths in Group 1. There was one aneurysm-related death in Group 2, and one in Group 3. CONCLUSION: The data highlights problems related to setting threshold diameters for abdominal aortic aneurysms in women, and to the interval between completion of surveillance and undergoing endoluminal or open surgical repair.