Solitary iliac branch endoprosthesis placement for iliac artery aneurysms.

BACKGROUND: Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. METHODS: All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. RESULTS: A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. CONCLUSIONS: Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

Cost-effectiveness of Elective Endovascular Aneurysm Repair Versus Open Surgical Repair of Abdominal Aortic Aneurysms.

OBJECTIVE/BACKGROUND: The aim of this study was to estimate the lifetime cost-effectiveness of endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in the Netherlands, based on recently published literature. METHODS: A model was developed to simulate a cohort of individuals (age 72 years, 87% men) with an abdominal aortic aneurysm (AAA) diameter of at least 5.5 cm and considered fit for both repairs. The model consisted of two sub-models that estimated the lifetime cost-effectiveness of EVAR versus OSR: (1) a decision tree for the first 30 post-operative days; and (2) a Markov model for the period thereafter (31 days-30 years). RESULTS: In the base case analysis, EVAR was slightly more effective (4.704 vs. 4.669 quality adjusted life years) and less expensive (€24,483 vs. €25,595) than OSR. Improved effectiveness occurs because EVAR can reduce 30 day mortality risk, as well as the risk of events following the procedure, while lower costs are primarily due to a reduction in length of hospital stay. The cost-effectiveness of EVAR is highly dependent on the price of the EVAR device and the reduction in hospital stay, complications, and 30 day mortality. CONCLUSION: EVAR and OSR can be considered equally effective, while EVAR can be cost saving compared with OSR. EVAR can therefore be considered as a cost-effective solution for patients with AAAs.

Perioperative prophylactic antithrombotic strategies in vascular surgery: current practice in the Netherlands.

AIM: The aim of this study was to evaluate the current practice of the use of perioperative antithrombotic drugs to prevent arterial thrombo-embolic complications during arterial vascular surgery by Dutch vascular surgeons. Aim was also to compare the results with the literature and to evaluate the effect of guidelines. METHODS: A comprehensive questionnaire was sent to all Dutch vascular surgeons performing arterial reconstructive surgery. RESULTS: The response rate was 84%. Acetylsalicylic acid (ASA) was continued perioperatively by most surgeons (91%). Clopidogrel was discontinued by the majority of respondents (65%). During operation 97% of surgeons administered unfractionated heparin (UFH) before arterial clamping. A minority (11%) measures peroperatively anticoagulant activity in patients' blood. After infrainguinal venous bypass most surgeons (81%) preferred monotherapy with vitamin K antagonists (VKA), in agreement with the Dutch guideline in this respect. Before the introduction of the guideline in 2005, a survey was performed in 2004. Results of our 2011 survey showed more respondents (6% to 11%) prescribed ASA or VKA according to these guidelines. CONCLUSION: This survey showed a recognizable pattern of variation for perioperative arterial thrombosis prophylaxis amongst Dutch vascular surgeons, in agreement with reports from other countries over the past 20 years. Although a higher percentage of surgeons complied in 2011 with existing guidelines than in 2004, guidelines were not completely met. Possibly because current guidelines are not fully supported by evidence and do not cover all aspects of perioperative arterial thrombosis prophylaxis. Clearly there is need for (more) convincing data based on RCT's concerning the various aspects of perioperative arterial thrombosis prophylaxis.

Prophylactic intraoperative antithrombotics in open infrainguinal arterial bypass surgery: a systematic review.

Unfractionated heparin (UFH) is used intraoperatively as antithrombotic by most vascular surgeons worldwide during infrainguinal bypass surgery (IABS) to reduce the risk of peroperative and early graft thrombosis. To reduce the harmful side effects of UFH (bleeding complications, HIT) and to reduce peroperative and early graft failure, other pharmaceuticals have been suggested for IABS. A systematic review was performed using MEDLINE, EMBASE and Cochrane databases. Only 9 studies on IABS and intraoperative antithrombotic use were eligible for review. Between studies heterogeneity was high and investigated study populations were often of small size. No study was retrieved comparing UFH to no-UFH. Dextran, human antithrombin and iloprost showed no beneficial effect compared to UFH alone for patency, mortality and morbidity. Low molecular weight heparin (LMWH) has potential benefits compared to UFH, but a statistically significant effect could not be demonstrated from the current review. The use of UFH during IABS to prevent intraoperative graft thrombosis has not been proven in randomized clinical trials. Dextran, human antithrombin and iloprost showed to be of no added beneficial effect for the patient compared to UFH alone. Data on the use of LMWH instead of UFH are promising, but no statistically significant benefit could be reproduced from literature. Results from a recent Cochrane review were favourable for LMWH, but it appeared that included data were not complete in that review. Randomized controlled trials are required for intra-operative use of antithrombotics and to improve peroperative and early patency after IABS.

Prophylactic perioperative anti-thrombotics in open and endovascular abdominal aortic aneurysm (AAA) surgery: a systematic review.

OBJECTIVE: Heparin is used worldwide by vascular surgeons as prophylaxis for arterial thrombo-embolic complications during open and endovascular arterial surgery. Possible harmful effect of heparin use is more perioperative blood loss, resulting in a higher morbidity and mortality. To evaluate the evidence for the use of heparin during aorto-iliac arterial surgery a review was performed. METHODS: A systematic review was performed of literature from MEDLINE, EMBASE and Cochrane databases, last search performed on March 8, 2012. RESULTS: For open surgery for abdominal aortic aneurysm (AAA), only 5 studies were eligible for review and for endovascular aneurysm repair (EVAR) only 1 study. Overall methodological quality of the included studies was poor. One randomised trial could be retrieved. Possible harmful effects of heparin were found of increasing operation time, more blood loss and more transfusion requirements when heparin was used for open AAA surgery in one study. No data were found comparing heparin to no intervention for EVAR. One study compared heparin to a direct thrombin antagonist during EVAR, showing no differences in clinical outcomes. CONCLUSION: Despite limitations this review showed no compelling evidence on the beneficiary effect of the prophylactic perioperative use of heparin during open surgery for (r)AAA. Authors will promote a randomised controlled multi-center trial on this topic for elective open surgical repair of AAA.

Clinical evaluation of a PHMB-impregnated biocellulose dressing on paediatric lacerations.

OBJECTIVE: To evaluate the clinical benefits, primarily tolerability and reduction in pain levels, associated with the use of a PHMB-impregnated biosynthetic cellulose dressing (Suprasorb X + PHMB) on paediatric heel lacerations. METHOD: These lacerations were caused when children, who were being transported on their parents' bicycles, got their heels trapped in the wheel spokes. Where these injuries just comprised skin contusion and laceration, treatment had previously comprised cleansing followed by application of conventional dressings and moist wound healing dressings. However, the high incidence of infection necessitated regular dressing changes, which caused parents and children stress and anxiety. This clinical evaluation assessed the benefits of a new treatment protocol, where the PHMB-impregnated biocellulose dressing was applied and left in situ until epithelialisation occurred. A cork splint was used for 3 days to prevent pes equinus and to let the ankle joint rest. Change in wound size (cm²), incidence of local infection, wound bed characteristics and pain levels (measured on a 0-10 paediatric pain scale) were assessed at 3-day intervals during the 14-day treatment period. Satisfaction with the dressing was also evaluated. RESULTS: Twenty children (mean age 5.6 years (± 1.33) were recruited into the study and included in the analysis. The mean baseline wound area was 8.60cm² (± 6.57). The mean time to complete wound closure was 12.95 days (± 7.69) with a mean total of 4.70 visits (± 1.56). The mean VAS pain score was 9.55 (± 0.69), compared with 0.15 (± 0.37) on day 14 (p<0.003). At the second visit (after 3 days) 17 of the 20 children were reported to be free of pain. No cases of local infection were noted. CONCLUSION: The dressing was found to be child and parent friendly. The evaluation also showed that it was well tolerated and achieved good healing outcome. It has now been incorporated into the clinic's treatment protocol for these wounds. CONFLICT OF INTEREST: None. The authors have no relevant financial interest in this article. All authors were involved in the critical revision of the manuscript for important intellectual content.

Cloned cattle derived from a novel zona-free embryo reconstruction system.

As the demand for cloned embryos and offspring increases, the need arises for the development of nuclear transfer procedures that are improved in both efficiency and ease of operation. Here, we describe a novel zona-free cloning method that doubles the throughput in cloned bovine embryo production over current procedures and generates viable offspring with the same efficiency. Elements of the procedure include zona-free enucleation without a holding pipette, automated fusion of 5-10 oocyte-donor cell pairs and microdrop in vitro culture. Using this system, zona-free embryos were reconstructed from five independent primary cell lines and cultured either singularly (single-IVC) or as aggregates of three (triple-IVC). Blastocysts of transferable quality were obtained at similar rates from zona-free single-IVC, triple-IVC, and control zona-intact embryos (33%, 25%, and 29%, respectively). In a direct comparison, there was no significant difference in development to live calves at term between single-IVC, triple-IVC, and zona-intact embryos derived from the same adult fibroblast line (10%, 13%, and 15%, respectively). This zona-free cloning method could be straightforward for users of conventional cloning procedures to adopt and may prove a simple, fast, and efficient alternative for nuclear cloning of other species as well.

Early assessment of skeletal muscle damage after ischaemia-reperfusion injury using Tc-99m-glucarate.

PURPOSE: After acute arterial obstruction of the lower extremity, muscle damage is the critical determinant for clinical outcome. The extent of muscle damage and limb viability are currently assessed by clinical examination, which is inaccurate. Tc-99m-pyrophosphate (PYP) has been applied for imaging ischaemia-reperfusion damage. More recently, a new imaging agent, Tc-99m-glucarate (GLUC), was introduced for delineating early myocardial infarction after ischaemia-reperfusion. The aim of this study was to determine if GLUC could delineate early skeletal muscle damage after ischaemia-reperfusion. Both tracers were used in a novel murine model of hindlimb ischaemia-reperfusion. METHODS: In anaesthetised mice, ischaemia of one hindlimb was maintained for 2, 3 and 4h using a tourniquet, followed by a reperfusion period of 1h. Additionally, reperfusion periods of 3, 24 and 96h were studied after 3h of ischaemia. PYP or GLUC was injected 45min before end of reperfusion. Concentrations of both agents were determined in blood, reperfused and contralateral muscle. Reperfused-to-contralateral muscle ratios were calculated. In separate experiments, muscle biopsies were obtained for histologic examination. RESULTS: Ischaemia and reperfusion damage was demonstrated histologically. Using scintigraphy GLUC depicted reperfusion significantly better than PYP. After 2, 3 and 4h of ischaemia, the reperfused-to-contralateral ratios for GLUC were 10.7+/-0.9, 8.9+/-0.9 and 8.6+/-1.1, as compared to 4.5+/-0.7, 4.9+/-0.4 and 4.5+/-0.4 for PYP (P<0.05 at all points). For longer periods of reperfusion, the ratios for GLUC decreased to similar levels as observed for PYP. CONCLUSION: The present study indicates that GLUC is a specific early marker of myocyte necrosis after ischaemia-reperfusion. GLUC may become an useful agent for clinical, early, non-invasive monitoring of skeletal muscle damage after ischaemia-reperfusion.

[Ultrasound guided percutaneous thrombin injection for treatment of a pseudoaneurysm after inguinal or brachial catheterization; good results in 14 patients]. / Echogeleide percutane trombine-injectie ter behandeling van een vals aneurysma in de lies of arm na katheterisatie; gunstige resultaten bij 14 patiënten.

OBJECTIVE: Evaluation of percutaneous ultrasound guided thrombin injection for treatment of postcatheterization pseudoaneurysms. DESIGN: Prospective. METHOD: In the period 1 April 1999-30 June 2000, all patients with postcatheterization pseudoaneurysms were included and primarily treated with ultrasound guided percutaneous thrombin injection. Under ultrasound guidance a 22 gauge needle was percutaneously positioned within the pseudoaneurysm and a thrombin solution was slowly injected to induce thrombosis. Distal pulses and ankle-brachial indexes were measured before and after the procedure. Colour Doppler ultrasound examination was repeated after 1 day, 1 week and 6 weeks. RESULTS: Fourteen patients were included: 6 men and 8 women, age range 50-79 year (mean: 66 year). Thirteen of 14 pseudoaneurysms, 12 femoral and 2 brachial pseudoaneurysms, were successfully treated with thrombin injection. Twelve pseudoaneurysms thrombosed after 1 injection. Because of recurrence 2 patients needed a second injection. One patient developed a recurrence after 2 injections and was referred for surgical treatment. Doses of thrombin needed varied between 150-1000 units. The whole procedure took 15 minutes on average. One patient developed a superficial infection 2 weeks after treatment at the site of the thrombosed pseudoaneurysm which needed incision and drainage in the outpatient department. No thromboembolic complications were found. CONCLUSION: Percutaneous thrombin injection appears to be an effective and safe procedure for the treatment of postcatheterization pseudoaneurysms.

Malignant fibrous histiocytoma of the stomach during pregnancy: a case report.

In this case report we describe a patient with a primary malignant fibrous histiocytoma of the stomach, diagnosed and operated upon during the sixth month of pregnancy. We stress the importance of a thorough diagnostic examination in cases of severe anaemia during pregnancy. Although very rare, malignancy of the gastrointestinal tract should be taken in consideration. No holding back is justified in diagnostic and therapeutic measurements because of pregnancy. Radiologic examination of the gastrointestinal tract should be replaced by endoscopy.

A method for long duration anaesthesia for a new hindlimb ischaemia-reperfusion model in mice.

To study the relationship between ischaemia-reperfusion and multiple organ dysfunction syndrome (MODS), a new anaesthesia method was required to be applied to C57BL/6 mice. These mice are also used in a well accepted, standardized model for MODS using intraperitoneally administered zymosan (zymosan induced general inflammation, ZIGI). The aim was to develop a new model for ischaemia-reperfusion with 6 h of anaesthesia. This and further specific requirements for the combination of ischaemia-reperfusion and the ZIGI method, made us select inhalational anaesthesia using isoflurane in oxygen. This study evaluates whether long-term anaesthesia confounds the results of ischaemia-reperfusion and the ZIGI model. In addition the benefits of using the analgesic buprenorphine were evaluated. Ischaemia was induced with a tourniquet around the hindlimb. Ischaemia and reperfusion were verified by imaging a radioactive tracer with a gamma-camera. It was established that anaesthesia with isoflurane in oxygen caused little perturbation of body temperature and respiratory rate. A survival rate of 89% without noteworthy influence on organs was obtained. Buprenorphine proved to provide adequate analgesia and had no influence on measured parameters. In our experimental setting, this model with long duration anaesthesia allowed us to induce ischaemia and reperfusion of the hindlimb without perturbation of measurements. It also allowed good exposure of the abdomen and facilitated combination with the ZIGI model.