Endovascular management of ruptured anastomotic pseudoaneurysm at the distal end of a prosthetic femoro-popliteal bypass: a "quick and easy fix".

BACKGROUND: Rupture of an anastomotic pseudoaneurysm after lower extremity prosthetic bypass is a rare problem, and the traditional mode of treatment has been open surgery. CASE DESCRIPTION: We report the endovascular management of a disrupted distal anastomosis of an above-knee femoro-popliteal Dacron bypass graft. Under local anesthesia and via a femoral cut-down, the Dacron graft was punctured and a 9 x 60 mm stent-graft was implanted resulting in successful pseudoaneurysm exclusion. The patient had an uneventful recovery. CONCLUSIONS: Stent-grafting may offer quick and easy rescue options for such challenging peripheral vascular lesions. Hippokratia 2015; 19 (2):179-181.

A meta-analysis and metaregression analysis of factors influencing mortality after endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: To determine factors that may influence the perioperative mortality after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) using metaregression analysis. METHODS: A meta-analysis of all English-language literature with information on mortality rates after endovascular repair of RAAAs was conducted. A metaregression was subsequently performed to determine the impact on mortality of the following 8 factors: patient age; mid-time study point; anaesthesia; endograft configuration; haemodynamic instability; use of aortic balloon; conversion to open repair; and abdominal compartment syndrome. RESULTS: The pooled perioperative mortality across the 46 studies (1397 patients) was 24.3% (95% CI: 20.7-28.3%). Of the 8 variables, only bifurcated approach was significantly associated with reduced mortality (p = 0.005). A moderate negative correlation was observed between bifurcated approach and haemodynamic instability (-0.35). There was still a strong association between bifurcated approach and mortality after simultaneously adjusting for haemodynamic instability, indicating that the latter was not a major factor in explaining the observed association. CONCLUSIONS: Endovascular repair of RAAAs is associated with acceptable mortality rates. Patients having a bifurcated endograft were less likely to die. This may be due to some surgeons opting for a bifurcated approach in patients with better haemodynamic condition. Further studies will be needed to clarify this.

Spirulina in clinical practice: evidence-based human applications.

Spirulina or Arthrospira is a blue-green alga that became famous after it was successfully used by NASA as a dietary supplement for astronauts on space missions. It has the ability to modulate immune functions and exhibits anti-inflammatory properties by inhibiting the release of histamine by mast cells. Multiple studies investigating the efficacy and the potential clinical applications of Spirulina in treating several diseases have been performed and a few randomized controlled trials and systematic reviews suggest that this alga may improve several symptoms and may even have an anticancer, antiviral and antiallergic effects. Current and potential clinical applications, issues of safety, indications, side-effects and levels of evidence are addressed in this review. Areas of ongoing and future research are also discussed.

Current evaluation of the dysphagic patient.

Dysphagia is a symptom so common and diverse that is often considered as a disease in its own right. Its severity can range from a trivial problem to a lethal condition. It can seriously compromise the quality of life of affected patients, therefore management should be prompt. The implications of dysphagia in healthcare costs are immense. Assessment of dysphagic patients is based on a comprehensive history and thorough examination. In the present review we discuss physiology, aetiology, diagnosis and management emphasizing the role of a multidisciplinary team approach. We also focus on the role of fibreoptic endoscopic evaluation of swallowing which revolutionized over recent years the assessment of the dysphagic patient.

Urgent carotid surgery in patients with crescendo transient ischaemic attacks and stroke-in-evolution: a systematic review.

OBJECTIVE: To document outcomes after urgent carotid surgery in patients with crescendo transient ischaemic attacks (CTIAs) and stroke-in-evolution (SIE). METHODS: A systematic review of the English-language literature using the MEDLINE and EMBASE databases "was undertaken from January 1984 through December 2007". Studies reporting the data after surgery for CTIAs and SIE were identified and stroke, stroke/death and stroke/death/major cardiac event rates calculated. The studies were divided into those reporting on CTIAs (group I) and those reporting on SIE (group II). RESULTS: From the databases, 34 relevant series (915 patients) were retrieved. After excluding those reports on CTIAs, SIE and other 'urgent' indications combined together and from which separate data could not be extracted, a total of 12 series with 176 patients reporting on CTIAs (group I) and 16 series with 114 patients reporting on SIE (group II) met the inclusion criteria. All the identified studies were case series of low methodological quality suffering from selection bias. Peri-operative stroke, stroke/death and stroke/death/major cardiac event rates were 6.5% (95% confidence interval (CI): 3.4-10.4), 9.0% (95% CI: 4.3-15.1) and 10.9% (95% CI: 5.5-17.9), respectively, in group I; and 16.9% (95% CI: 9.2-26.2), 20.0% (95% CI: 12.5-28.6) and 20.8% (95% CI: 13.2-29.6), respectively, in group II. CONCLUSIONS: The combined risk of neurological and cardiac complications following urgent carotid surgery for unstable neurological symptoms, such as CTIAs and SIE, is higher than that anticipated after elective surgery for stable symptoms.

Current endovascular management of the ischaemic diabetic foot.

Ischaemic diabetic foot ulcers pose a significant problem which is associated with a high likelihood of amputation. With the advent of endovascular surgery, the management of lower limb arterial lesions in the diabetic population has become more appealing. Coronary 0.014 monorail guide wires, appropriate sized angioplasty balloons and stents, and subintimal recanalisation, are all useful adjuncts and techniques to achieve revascularization. This article reviews the modern endovascular management of the diabetic foot.

Cerebral perfusion patterns in patients with extracranial carotid atherosclerosis and the impact of carotid stenting. A review.

Patients with extracranial carotid atherosclerosis, either symptomatic or asymptomatic, demonstrate altered cerebral perfusion. Carotid revascularization procedures, such as carotid endarterectomy or stenting, aim mainly at stroke prevention from thromboembolic events, whereas their effects on cerebral perfusion, particularly those seen after carotid stenting, have not been extensively examined. Moreover, ischemia and reperfusion injury have been recognized as devastating complications of these procedures. The present work is a literature review of cerebral perfusion patterns in normal individuals and in patients with carotid artery stenosis prior to and after carotid stenting.

An "all-comers" venous duplex scan policy for patients with lower limb varicose veins attending a one-stop vascular clinic: is it justified?

OBJECTIVE: To determine whether clinical assessment could predict the correct management of patients with varicose veins (VVs), select those who would need duplex scanning, and identify deep venous reflux (DVR). METHODS: Prospective study of 342 consecutive limbs with VVs. These were divided into 3 groups: 170 (50%) limbs with primary VVs without skin changes (group I), 37 (11%) with recurrent VVs without skin changes (group II), and 135 (39%) with primary or recurrent VVs with skin changes (group III). Clinicians were asked to document whether they would normally request a duplex scan because of clinical uncertainty. Agreement between decision-making based on clinical and on duplex findings was documented. RESULTS: Agreement between clinical and duplex findings for groups I, II, and III was 82%, 59%, and 67%, respectively. In 112 cases (66%) in group I, clinicians felt certain about the diagnosis and yet duplex scanning revealed they were wrong in 12% of cases. In group II, clinicians would request a duplex scan because of clinical uncertainty in 30 (81%) cases. In group III, the sensitivity, specificity, positive and negative predictive value of clinical assessment in detecting DVR was 32%, 77%, 24%, and 83%, respectively. CONCLUSIONS: Clinical evaluation of patients with VVs is unreliable in planning their management. Clinicians can neither predict those who will require duplex scanning nor correctly identify DVR. Even experienced surgeons often "get it wrong" when assessing primary uncomplicated veins despite being certain about the diagnosis. Therefore, an "all-comers" duplex imaging policy should be implemented if optimal management is to be achieved.

The impact of diabetes on current revascularisation practice and clinical outcome in patients with critical lower limb ischaemia.

OBJECTIVE: To compare current revascularisation practice and outcome in diabetic and non-diabetic patients presenting with critical limb ischaemia (CLI) to a single vascular surgeon. METHODS: Data for 113 patients presenting with CLI were collected prospectively over a 3-year period. Forty-four (39%) were diabetic. Treatment was classified as percutaneous angioplasty, arterial reconstruction, primary major amputation, and conservative therapy. Main outcome measures were 30-day mortality, major amputation, survival, and amputation-free survival. RESULTS: Diabetic patients were more likely to present with gangrene, give a history of angina, be treated with nitrates and statins, and have lower cholesterol levels. No significant differences were found in the initial treatment options between diabetics and non-diabetics: angioplasty 39 vs 26%, surgical revascularisation 34 vs 33%, primary major amputation 9% vs 17%, and conservative treatment 11 vs 19% (p = ns in all). There were eight deaths (7%) within 30-days. At follow-up (1-44 months, median 14 months), rates of major amputation and death for the entire population were 23 and 8%, respectively. The 12-month cumulative survival and amputation-free survival rates were 90 and 72%, respectively. When comparing diabetic to non-diabetic patients, there were no significant differences in the 30-day mortality (6.8 vs 7.2%, p = 0.4), cumulative survival (93 vs 89% at 12 months, log-rank test: 0.00, p = 0.9), amputation-free survival (71 vs 73% at 12 months, log-rank test: 0.00, p = 0.99), and major amputation rates (22.7 vs 23.1% at 12 months, p = 0.96). Similarly, there were no differences in limb salvage rates between diabetic and non-diabetic patients undergoing revascularisation procedures (78 vs 90% at 12 months, log-rank test: 2.04, p = 0.15). CONCLUSIONS: In current practice, an aggressive multidisciplinary approach in diabetic patients presenting with CLI leads to similar limb salvage, amputation-free survival, mortality, and major amputation rates to those seen in non-diabetic patients. The presence of diabetes should not deter clinicians from attempting revascularisation by means of angioplasty or surgical reconstruction.

Routine measurement of radioisotope left ventricular ejection fraction prior to vascular surgery: is it worthwhile?

OBJECTIVE: To determine whether estimation of left ventricular (LV) ejection fraction (EF) by means of multiple gated acquisition (MUGA) scanning could reliably stratify cardiac risk prior to elective major vascular surgery. METHODS: A review of the English-language literature. RESULTS AND CONCLUSIONS: Twenty-two studies enrolling a total of 3096 patients were identified from 1984 to date. Selection bias, blinding of the results, different cut-off limits, and several retrospective studies were some of the problems preventing a comprehensive analysis. The resting LVEF was not found to be a consistent predictor of perioperative ischaemic cardiac events. In the perioperative phase, poor LV function was, mainly, predictive of congestive heart failure, and, in the long-term, of cardiac outcome. The presence of myocardial wall motion abnormalities was also associated with both a higher chance of postoperative cardiac complications and a worse long-term cardiac outcome. Although measurements of LV function seem to play a key role in defining a patient's long-term prognosis, the value of routinely measuring LVEF preoperatively is limited and, therefore, MUGA scanning cannot be recommended as a general screening test. Despite this, it has been widely used for cardiac risk assessment in vascular surgery, and only recently its popularity has started declining. Other tests, such as stress-echocardiography and myocardial perfusion imaging, used selectively in moderate-risk patients can refine prediction of cardiac risk. In the future, gated stress myocardial perfusion scintigraphy, perhaps combined with ANP/BNP plasma level determination, may become a first choice test in preoperative cardiac risk assessment.

Arteriovenous fistula of the lateral superior and inferior geniculate arteries. A unique cause of a "recurrent prepatellar bursa.

We report a previously undocumented case of an arteriovenous fistula of the superior and inferior lateral geniculate arteries presenting with what was thought to be a recurrent prepatellar bursa requiring repeated drainage and excision. The diagnosis was made by arteriography. Surgical exploration and ligation of the feeding and draining vessels, via a posterior approach, alleviated the symptoms. Vascular injury should be suspected in patients presenting with recurrent postoperative hematomas or hemarthroses following surgery on the knee.

Use of the intra-aortic balloon pump to stop gastrointestinal bleeding.

Temporary aortic occlusion can be lifesaving in selected conditions. We describe the unorthodox use of an intra-aortic balloon pump without counterpulsation to achieve temporary vascular control in a patient with shock caused by rapid upper gastrointestinal bleeding. The technique of aortic balloon occlusion has been reported in several clinical circumstances, primarily trauma. However, its use to increase blood pressure and gain time for resuscitation before laparotomy for catastrophic gastrointestinal bleeding has not previously been described.

Retroaortic left renal vein and its implications in abdominal aortic surgery.

The embryological development of the retroperitoneal venous system is a complex process. As a result, the anatomy of the inferior vena cava (IVC) and renal veins shows extensive variability. Improper completion of this process may lead to six anatomical variants: retroaortic left renal vein (LRV) types I and II, circumaortic venous collar, duplication of the IVC, transposition or left-sided IVC, and preaortic iliac confluence. All six are infrequent, but may be encountered during abdominal aortic reconstruction and pose challenging problems to the operating surgeon. Failure to appreciate these anomalies can lead to inadvertent injury and major venous bleeding. Preoperative diagnosis can be made on a CT scan, but this is not always performed prior to aortic surgery. In this report, we analyze two cases of retroaortic LRV complicating abdominal aortic aneurysmectomy, describe the most common infrarenal venous anomalies encountered during aortic surgery, and briefly review the literature.

Primary stenting for chronic total occlusion of the infrarenal aorta.

PURPOSE: To present a rare case of chronic total occlusion of the infrarenal aorta treated with a self-expanding endoluminal stent implanted without preliminary dilation. METHODS AND RESULTS: A 68-year-old woman presented with severe bilateral buttock and thigh claudication. Angiography revealed total occlusion of the infrarenal abdominal aorta and relatively normal iliac vessels. Via a right groin puncture and a 9-F sheath, a 14-mm x 5-cm self-expanding Wallstent was deployed in the abdominal aorta and expanded with an angioplasty balloon. Completion angiography showed successful recanalization of the aorta with satisfactory distal flow. Palpable distal pulses were restored, and the patient's symptoms were alleviated. She remained asymptomatic until her death from a major stroke 11 months after aortic stent implantation. CONCLUSIONS: Primary stenting may be considered a viable alternative to conventional surgery in selected patients with total infrarenal aortic occlusion.

Rupture of the abdominal aorta in patients with Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a heterogeneous inherited disorder of collagen synthesis. Type IV is frequently associated with major vascular catastrophes and challenges the vascular surgeon with its varied clinical presentation and the difficulty of vascular repair. Rupture of the abdominal aorta is one of the most serious complications and is associated with nearly 100% mortality rate. We describe here three patients with type IV EDS.