Efficacy and Durability of Percutaneous Deep Vein Arterialization: A Systematic Review.

BACKGROUND: Endovascular deep vein arteriaization (DVA) is a novel technique aimed at salvaging peripheral arterial disease unamenable to conventional surgical intervention. This study aims to review contemporary literature on the efficacy, safety, and durability of DVA on patients with no-option critical limb ischemia (NO-CLI). METHODS: The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using predefined search terms of "percutaneous deep vein arterialization" or "percutaneous deep venous arterialization" in PubMed, Web of Sciences, OvidSP, and Embase. Only studies with 5 or more patients were included, and studies involving open or hybrid DVA were excluded. The primary outcomes included technical success and primary amputation rates. Secondary outcomes included rates of wound healing, complication, reintervention, and all-cause mortality. RESULTS: Ten studies encompassing a total of 233 patients were included. Patients were primarily those deemed to have NO-CLI. The median follow-up period was 12 months (range 1-63 months). The technical success rate was 97% (95% confidence interval [CI] 96.2%-97.9%) and the major amputation rate was 21.8% (95% 21.1%-22.4%). The wound healing rate was 69.5% (95% CI 67.9-71.0%), complication rate was 13.8% (95% CI 11.7%-15.9%), reintervention rate was 37.4% (95% CI 34.9%-39.9%), and all-cause mortality rate was 15.7% (95% CI 14.1%-17.2%). CONCLUSIONS: Our study showed that endovascular DVA is safe for patients with NO-CLI. Nonetheless, studies were small with follow-up period of less than 1 year. There is currently lack of level 1 evidence to recommend routine use in patients with NO-CLI.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms.

OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Prevalence and predictors of radiological left common iliac vein compression in asymptomatic patients.

OBJECTIVE: The aim of this study was to investigate the prevalence of radiological left common iliac vein (LCIV) compression among the asymptomatic population and identify possible predictors. METHODS: Contrast-enhanced abdominal and/or pelvic computed tomography scans of eligible asymptomatic patients were examined. The LCIV diameter was measured from different horizontal planes in the venous phase using PACSView. Degree of LCIV compression (Dc) was calculated by a predefined formula and graded as insignificant (Dc < 25%), mild (≥25% Dc < 50%), moderate (≥50% Dc <75%), and severe (Dc ≥ 75%). Venous stenosis was defined as a Dc of ≥50%. Comparison of variables, including gender, age, body mass index (BMI), and comorbidities was performed between the different grades of LCIV compression. RESULTS: Between November 2019 and July 2022, 1698 eligible asymptomatic patients (53.1% females; mean age, 39.3 ± 11.8 years; mean BMI, 22.9 ± 3.6 kg/m2) were reviewed. The mean Dc was 46.2% (range, 0.29%-90.4%). Insignificant, mild, moderate, and severe compression were distributed in 14.5%, 38.0%, 42.2%, and 5.2% of the cohort population, respectively. Prevalence of venous stenosis was higher in females than males (58.1% vs 42.2%; χ2 = 15.52; P < .001). Females aged ≥25 and <35 years accounted for the highest proportion of venous stenosis than other age groups and was a significant predictor (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.74-7.79; P < .001). In the Asian BMI classification group, being underweight is associated with venous stenosis (OR, 4.69; 95% CI, 2.70-8.14; P < .001) and obesity may be a protective factor (OR, 0.38; 95% CI, 0.23-0.64; P < .001). There is an inverse relationship between Dc and age and BMI. CONCLUSIONS: The prevalence of radiological LCIV compression on computed tomography scans was high, but all patients were asymptomatic. Female gender, especially those aged ≥25 and <35 years, and underweight were possible predictors for venous stenosis.

Contemporary Outcomes of Endovascular and Open Surgical Repair for Mycotic Aortic Aneurysms: A Systematic Review.

BACKGROUND: To perform a systematic review on contemporary outcomes of endovascular repair and open surgical repair (OSR) for the treatment of mycotic aortic aneurysm (MAA). METHODS: A comprehensive literature search on the management of MAAs with endovascular repair or OSR was performed between January 1998 and January 2023. Patient demographics, early and late outcomes were analyzed with respect to treatment modality and MAA location. RESULTS: Forty-eight articles were included, encompassing a total of 1,358 patients (75.8% male; mean age 66.9 years; 1,372 aneurysms) treated by open (49.8%) or endovascular (50.2%) repair. Salmonella spp., and Staphylococcus spp. were the most prevalent pathogens in Asian and European countries respectively. An increasing number of descending thoracic MAAs were managed by endovascular repair (27.9% vs. 12.8%). Early mortality rates for supra- and infra-renal MAAs managed by endovascular repair were lower than OSR (suprarenal 5.4% vs. 43.2%; infrarenal 1.8% vs. 16.7%). Overall, endovascular repair demonstrated lower intraoperative (1.0% vs. 1.8%) and early mortality (6.5% vs. 15.9) rates than OSR. However, endovascular repair was associated with higher late sepsis rate (5.7% vs. 0.9%) and reintervention rate (17.6% vs. 7.3%). Pooled survival rates at 1- and 5-year were similar between the 2 groups. CONCLUSIONS: Current literature suggest that endovascular repair is an effective and safe alternative to OSR for descending thoracic, suprarenal, and infrarenal MAAs. However, endovascular repair is associated with higher risk of infection-related complications and reintervention during follow-up.

Safety and Efficacy of Inner Branched Stent-Graft in the Treatment of Aortic Arch Disease: A Systematic Review.

OBJECTIVE: To provide a descriptive overview on the contemporary outcomes of thoracic endovascular arch repair with inner branched endoprosthesis (bTEVAR) for the treatment of aortic arch pathologies. METHODS: A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Pre-defined search terms were used to interrogate PubMed and OVID Medline databases from January 1999 to July 2022. Patient characteristics, indication for treatment, procedural data, mortality rates, postoperative complications, and reintervention rate during follow-up were evaluated. RESULTS: Nineteen articles were included, encompassing a total of 618 patients who received bTEVAR, most of which were double-branched (63.9%, n=395). The main indication for treatment was aneurysm secondary to chronic aortic dissection (38.8%, n=240/618) with a mean maximum diameter of 58.3±11.4 mm. Pooled mean technical success rate was 97.4±4.4% (95% confidence interval [CI]=95.1%-99.5%); 2 and 3 patients required conversion to chimney technique and open repair, respectively. Among the pooled rates of early complications, postoperative stroke was the highest (10.5%; 95% CI=6.8%-14.3%). Thirty-day and in-hospital mortality rate was 5.5% (95% CI=2.6%-9.7%). Forty patients (6.5%; 95% CI=2.5%-9.5%) required early reintervention. During a mean follow-up of 20.7±13.5 months, the mortality rate was 18.2% (n=108/593; 95% CI=8.6%-20.6%) where 12 (11.1%) were aortic-related. Pooled late reintervention rate was 9.6% (95% CI=4.8%-14.3%). Comparison of demographics and outcomes found no significant difference between single and double bTEVAR. CONCLUSION: Branched thoracic endovascular aortic repair is a promising approach for aortic arch pathologies with a high technical success rate despite a steep learning curve. However, contemporary outcomes reflect that postoperative stroke remains the predominant concern. Further experience and long-term follow-up are required to sufficiently elucidate the safety and durability of bTEVAR in the management of aortic pathologies for high-risk patients. CLINICAL IMPACT: This systematic review summarized the contemporary outcomes of thoracic endovascular aortic repair with different inner branched stent-grafts for the management of aortic arch pathologies. Pooled results from nineteen studies with 618 patients demonstrated a high technical success rate and an acceptable mortality rate. However, postoperative stroke remains the major concern. Long-term follow-up is needed to evaluate its durability.

Outcomes After Endovascular Aortic Intervention in Patients With Connective Tissue Disease.

Importance: Endovascular treatment is not recommended for aortic pathologies in patients with connective tissue diseases (CTDs) other than in redo operations and as bridging procedures in emergencies. However, recent developments in endovascular technology may challenge this dogma. Objective: To assess the midterm outcomes of endovascular aortic repair in patients with CTD. Design, Setting, and Participants: For this descriptive retrospective study, data on demographics, interventions, and short-term and midterm outcomes were collected from 18 aortic centers in Europe, Asia, North America, and New Zealand. Patients with CTD who had undergone endovascular aortic repair from 2005 to 2020 were included. Data were analyzed from December 2021 to November 2022. Exposure: All principal endovascular aortic repairs, including redo surgery and complex repairs of the aortic arch and visceral aorta. Main Outcomes and Measures: Short-term and midterm survival, rates of secondary procedures, and conversion to open repair. Results: In total, 171 patients were included: 142 with Marfan syndrome, 17 with Loeys-Dietz syndrome, and 12 with vascular Ehlers-Danlos syndrome (vEDS). Median (IQR) age was 49.9 years (37.9-59.0), and 107 patients (62.6%) were male. One hundred fifty-two (88.9%) were treated for aortic dissections and 19 (11.1%) for degenerative aneurysms. One hundred thirty-six patients (79.5%) had undergone open aortic surgery before the index endovascular repair. In 74 patients (43.3%), arch and/or visceral branches were included in the repair. Primary technical success was achieved in 168 patients (98.2%), and 30-day mortality was 2.9% (5 patients). Survival at 1 and 5 years was 96.2% and 80.6% for Marfan syndrome, 93.8% and 85.2% for Loeys-Dietz syndrome, and 75.0% and 43.8% for vEDS, respectively. After a median (IQR) follow-up of 4.7 years (1.9-9.2), 91 patients (53.2%) had undergone secondary procedures, of which 14 (8.2%) were open conversions. Conclusions and Relevance: This study found that endovascular aortic interventions, including redo procedures and complex repairs of the aortic arch and visceral aorta, in patients with CTD had a high rate of early technical success, low perioperative mortality, and a midterm survival rate comparable with reports of open aortic surgery in patients with CTD. The rate of secondary procedures was high, but few patients required conversion to open repair. Improvements in devices and techniques, as well as ongoing follow-up, may result in endovascular treatment for patients with CTD being included in guideline recommendations.

A pilot study to evaluate a novel localized treatment to stabilize small- to medium-sized infrarenal abdominal aortic aneurysms.

OBJECTIVE: There is no proven therapy to reduce growth rates of small- to medium-sized abdominal aortic aneurysms (AAAs). Ex vivo and animal studies have demonstrated that a novel stabilizing agent, 1,2,3,4,6-pentagalloyl glucose (PGG), delivered locally to the aneurysm sac, can bind to elastin and collagen to re-establish strength and resist enzymatic degradation. We aimed to demonstrate that a one-time administration of PGG solution to the aneurysm wall is safe and potentially effective to slow the growth of small- to medium-sized AAAs. METHODS: Patients with small- to medium-sized infrarenal AAAs (maximum diameter <5.5 cm) were recruited. Via transfemoral access, a 14F or 16F dual-balloon delivery catheter was introduced into the aneurysm sac. A single, 3-minute, localized endoluminal infusion of PGG was delivered via a 'weeping' balloon to the aneurysm wall. Independent core laboratory measurements of maximum aneurysm sac diameter and sac volume measurements based on computed tomography angiography (CTA) were used for assessments at 1, 6, 12, 24, and 36 months. The primary endpoints were technical success and safety (major adverse events at 30 days). The secondary endpoint was growth stabilization, defined as freedom from aneurysm sac enlargement (diameter increase >5 mm per year or volume increase of >10% per year). RESULTS: Twenty patients (19 male) were enrolled at five centers from May 2019 to June 2022 (mean age, 67.8 years; range, 50-87 years). All procedures were technically successful. The safety profile was consistent with standard interventional procedures. Four patients demonstrated transient elevations of liver enzymes levels that returned to normal by 30 days with no clinical symptoms. Through November 2022, follow-up CTA data is available on the first 11 patients. The average changes in maximum aneurysm diameter from baseline to 6, 12, 24, and 36 months were 0.2 mm, 1.1 mm, 1.2 mm, and 0.8 mm, respectively, and the average changes in volume were 2.0%, 9.6%, 18.1%, and 11.6%, respectively. At 12 months, none of the aneurysms showed growth >5.0 mm, and three had volume growth >10%. CONCLUSIONS: The early results of this first-in-human, small cohort study demonstrated that a single, localized PGG administration to patients with small- to medium-sized infrarenal AAAs is safe. Longer term follow-up on all 20 treated patients is needed to better assess the potential impact on aneurysm growth.

Trans-Cervical Endovascular Management of Saccular Aneurysm of the Extracranial Internal Carotid Artery Using a Self-Expanding Nitinol Base ePTFE Covered Stent.

Saccular aneurysm of the extracranial internal carotid artery is rare. We present a 56-year-old lady presented with a progressively enlarging pulsatile swelling over the right neck, and the right internal carotid artery aneurysm was successfully treated with trans-carotid endovascular stenting of right common to right carotid artery using a self-expanding nitinol base ePTFE covered stent (COVERA Plus™ stent, Bard, Tempe, USA). The external carotid artery was prophylactically embolised to prevent back bleeding. New generation covered stents have consistently improved flexibility and conformability, and this is to our knowledge the first reported case in the world's literature of using this type of self-expanding nitinol base ePTFE covered stent in endovascular stenting of carotid artery aneurysms, with excellent short-term results.

Theoretical Feasibility of Using Arch Branched Endograft Devices for Repair of Post Type A Aortic Dissection in Patients With Prior Ascending Aortic Replacement.

PURPOSE: Ascending aortic replacement is a common emergency procedure for treating acute type A aortic dissection. Secondary open or endovascular interventions for residual arch pathologies is difficult because of adhesions, short prosthetic grafts, and distorted anatomies. Aortic arch branched stent grafts have emerged as a potential solution for these patients if they have suitable anatomical conditions. This study aimed to evaluate the theoretical anatomical and technical feasibility of 2 currently used aortic arch branch endografts in patients who had prior replacement of the ascending aorta. MATERIALS AND METHODS: All patients who had a prosthetic ascending aortic or hemiarch replacement for acute type A dissection in a single institution between January 2013 and December 2018 were included. Contrast computed tomography images on the most recent follow-up were analyzed on a 3-dimensional workstation. Morphological parameters were measured individually for the ascending aorta, aortic arch, supra-aortic branches, and access iliac arteries. The computed tomography scan of each patient was individually evaluated for anatomical suitability for the arch branched and double-branch devices according to set selection criteria. RESULTS: Computed tomography images of 56 patients (median age of 57 years, 45 males) were reviewed. Based on our evaluation, 26 patients (46.4%) were good candidates for an endovascular arch branched device. It would be feasible for 13 patients (23.2%), but prudent preoperative planning was required due to complicated anatomy. The other 17 patients (30.4%) were unsuitable because they met at least 1 exclusion criterion. Short prosthetic grafts, extreme graft angulations, and extensive dissections in the supra-aortic branches were the main reasons for exclusion. CONCLUSION: Endovascular repair using arch branched endografts is feasible in patients with prior ascending aortic arch or hemiarch replacement for acute type A aortic dissection. The most common anatomical conditions that may influence the feasibility of the arch branched endograft procedure include insufficient proximal seal length, severe angulation of the graft, and extensive aortic dissection within the supra-aortic vessels.

Risk factor analysis and treatment outcome of patients with spontaneous isolated celiac axis or superior mesenteric artery dissection.

BACKGROUND: Spontaneous isolated mesenteric artery (celiac axis or superior mesenteric artery [SMA]) dissection (IMAD) is a rare clinical entity. The aim of the present study was to examine the patient demographics, comorbidities, clinical and radiologic features, management, and prognosis and to identify the risk factors predictive of symptoms. METHODS: We performed a single-center, retrospective review from November 2005 to November 2021 of prospectively collected data from patients with a diagnosis of IMAD. The clinical data and radiologic images were reviewed, and statistical analysis was performed to compare the symptomatic and asymptomatic groups. RESULTS: A total of 78 patients were identified. Of the 78 patients, 24 (31%) had had celiac dissections, 51 (65%) had had SMA dissections, and 3 (4%) had had both celiac and SMA dissections. The mean age was 57.7 years (range, 36-84 years), with a male predominance (86%). More than one half (55%) of the patients had had hypertension. In addition, 29 patients (37%) were symptomatic, and 24 (31%) had been admitted to the hospital. The symptomatic patients with celiac axis dissections were more likely to have thrombosis (P = .02), significant stenosis (P = .01) or branch extension (P = .02). The symptomatic patients with SMA dissections were more likely to have a smaller artery diameter (P = .07), a longer dissection length (P = .05), thrombosis (P < .001), significant stenosis (P < .001), or branch extension (P = .003). The symptomatic patients were more likely to have been treated with antiplatelet or anticoagulant therapy (P < .001). Only three patients had undergone an intervention. Seven patients (9%) had died of unrelated causes. The Kaplan-Meier survival analysis showed a 5-year survival rate of 96% and 10-year survival rate of 91%. CONCLUSIONS: IMAD is an uncommon disease entity with a risk of visceral ischemia. Nonetheless, most of these patients can be treated conservatively with medication, with only a small minority requiring emergency surgery.

Risk Factor Analysis and Long-Term Outcomes in Patients with Endovascular Revascularization for Intermittent Claudication or Chronic Limb-Threatening Ischemia.

BACKGROUND: The aim of this study is to review long-term outcome and identify risk factors for patients with peripheral arterial disease (PAD) with percutaneous transluminal angioplasty/stent as a primary treatment strategy for intermittent claudication (IC) or chronic limb-threatening ischemia (CLTI). METHODS: A retrospective cohort study with data collected prospectively from Clinical Data Analysis and Reporting System, departmental database, and Clinical Management System. All patients who underwent endovascular procedures for PAD between January 2011 and December 2020 were identified. The primary outcomes are overall survival and amputation-free survival. Predictive factors for OS and AFS were determined using Cox Model. RESULTS: A total number of 640 patients with PAD (IC, n = 243; CLTI, n = 377) underwent endovascular percutaneous transluminal angioplasty/stenting for PAD from January 2011 to December 2020. Patients with CLTI had a significantly higher 30 days readmission rate (18.8% vs. 6.5%, P < 0.001), emergency reoperation within 30 days (3.4% vs. 0%, P = 0.002), and death within same admission (2.7% vs. 0%, P = 0.008) compared to IC patients. The overall survival and amputation-free survival rates were significantly lower in CLTI patients (P < 0.0001 and P < 0.0001, respectively). On Cox multivariate analysis, CLTI was strongly predictive of all-cause mortality and amputation (hazard ratio [HR] 2.33 and HR 14.92, respectively). In patients with CLTI, chronic kidney disease was an independent predictor of mortality and amputation (HR 1.66 and HR 2.36, respectively). Smoking and ischemic heart disease were also independent predictors of mortality in this subgroup (HR 2.06 and HR 2.43, respectively). CONCLUSIONS: Although patients with IC and CLTI both manifest from atherosclerotic occlusive disease of the lower limb arteries, these patients may have different clinical outcomes with significant mortality occurred in both IC and CLTI groups. In patients with IC, the risk of amputation was less than 1% at 5 years following revascularization.

Endovascular Thrombus Aspiration and Catheter-Directed Thrombolysis for Acute Thromboembolic Renal Artery Occlusion.

PURPOSE: We report a case of revascularization for an occluded renal artery using endovascular renal thrombus aspiration followed by catheter-directed thrombolysis. CASE REPORT: A 56-year-old man presented with sudden onset severe left-sided abdominal and loin pain for 6 hours. Urgent computed tomography (CT) angiogram showed occlusion of left renal artery. Emergency selective left renal angiogram and thrombus aspiration using a 5-French Cobra catheter was performed. Catheter-directed thrombolysis with urokinase was initiated after aspiration thrombectomy. Angiogram 24 hours after thrombolysis showed the left renal artery and its segmental branches were successfully revascularized. Patient was put on anticoagulation after operation and his renal function recovered well. CONCLUSION: Percutaneous aspiration thrombectomy with conventional catheters combined with intra-arterial local fibrinolysis could be used to salvage the renal function in case of complete renal artery thromboembolic occlusion.

COVID-19 related thrombosis: A mini-review.

INTRODUCTION: COVID-19 associated VTE is a new disease entity with high morbidity and mortality. The aim of this paper is to review contemporary emerging literature on the incidence, pathophysiology, predictive prognostic indicators, and management consensus for Covid-19 related thrombotic complications, in particular DVT and PE. METHODS: A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed. References of review articles were further screened according to the exclusion criteria. RESULTS: In total, 154 records were identified and 20 duplicates were removed. A final 68 articles were included in the qualitative analysis. COVID-19 related thrombosis can affect multiple organs of the body, presenting in the form of arterial or venous thrombosis such as ischemic stroke, myocardial infarction, mesenteric ischemia, limb ischemia, DVT, or PE. DVT and PE has an overall incidence of 6-26%, and severely ill COVID-19 patients have even higher incidence of thromboembolism. On the other hand, incidence of arterial thromboembolism is much lower with incidence of 0.7%-3.7%. D-dimer is found to be an independent risk factor, and IMPROVE score, Caprini score, and Padua score have all been used as predictors. International guidelines suggest the use of low molecular weight heparin (LMWH) or fondaparinux for prophylaxis of VTE, and therapeutic dosage of weight adjusted LMWH for treatment if confirmed diagnosis. CONCLUSIONS: Contemporary rapidly evolving evidence shows that COVID-19 associated thrombosis was a novel clinical entity, especially in severely ill COVID-19 patients. There are multiple society-driven guidelines only, but without any level 1 evidence for management regimen. The ideal dose for prophylaxis is not established and may vary depending on balance of bleeding and thrombosis risk. The risk of bleeding may be increased in patients in intensive care unit.

Modification of protocol with one extra drop of endovascular cyanoacrylate improved closure rates in incompetent great saphenous veins.

INTRODUCTION: Great saphenous vein diameter (GSV) of >8 mm was predictor of recanalization following Venaseal cyanoacrylate treatment. The aim of this study was to report our modified protocol with a single extra-drop for treatment for GSV>8 mm, and comparative duplex results in closure rates. METHODS: Patients in our single-centre registry treated with Venaseal were followed up by serial duplex examinations at week 1 and month(s)- 1, 6, 12, 18, 24, and then annually. The primary endpoint was successful obliteration of the GSV, secondary endpoints were closure distance from Saphenofemoral junction (SFJ), presence of endovenous glue-induced thrombosis (EGIT) or deep vein thrombosis. RESULTS: A total of 243 legs in 123 consecutive patients with duplex-proven SFJ/GSV incompetence were included in this study between September 2014 and October 2020. The median duplex follow-up period of this cohort of patients was 24 (range 0.2-58) months. Comparing closure rates in GSV diameter ≥8 mm treated with normal protocol, the 'extra-drop protocol' significantly improved closure rates (p = .034). However, the closure rates of ≥8 mm GSV treated with 'extra-drop protocol' was still not as good as GSV <8 mm (p < .001). There were no statistically significant differences in the stump distance between the three groups and no difference in the occurrence of EGIT. There were no deep vein thrombosis. CONCLUSION: Our experience showed that VenaSeal cyanoacrylate worked best in GSV<8 mm diameter. Even in GSV diameter of ≥8 mm which has a higher recanalization rate on follow-up duplex, our modified extra-drop protocol significantly improved the closure rates, and did not predispose to development of EGIT.

Not All Gymnastic Exercises Are Suitable for Everyone: An Uncommon Cause of Thoracic Outlet Syndrome: A Case Report.

CASE: A 34-year-old man spontaneously presented with bilateral thoracic outlet syndrome over 1 year. He was a gymnast active in rowing and weightlifting, with "slanted" shoulders, narrowed costoclavicular spaces, and well-developed scalene muscles. Imaging revealed fractures of multiple bilateral upper ribs in various degrees of nonunion. The patient's symptoms improved after activity modification and physiotherapy. CONCLUSIONS: Atraumatic spontaneous rib fracture-nonunions are an uncommon cause of thoracic outlet syndrome; this diagnosis should be considered in physically active patients presenting with typical symptoms with atypical anatomy.

Acute Thrombosis of an Infrarenal Abdominal Aortic Aneurysm Presenting as Bilateral Critical Lower Limb Ischemia.

BACKGROUND: Intraluminal thrombosis in the aneurysm sac is commonly seen in abdominal aortic aneurysm (AAA). Complete acute thrombosis of an AAA is a rare and catastrophic event. METHOD: We report a patient with acute AAA thrombosis presenting as bilateral lower limbs critical ischemia. A79-year-old male with a past history of AAA presented with acute onset of bilateral leg pain, coolness, weakness and numbness. His lower extremity pulses including femorals were absent bilaterally on physical examination. Urgent computed tomography angiography showed an infrarenal AAA measuring 45 mm in diameter. The aneurysm sac and bilateral common iliac arteries were completely occluded. Emergency open repair of AAA and bilateral iliac thrombectomy were successfully performed under general anesthesia. RESULT: Bilateral femoral pulses were present and the neurological deficits were completely resolved after operation. Patient recovered well and was asymptomatic at 3-month follow-up. CONCLUSION: Acute thrombosis of aortic aneurysm could be an unusual cause of lower limb ischemia, prompt diagnosis followed by surgical revascularization is essential to avoid prolonged ischemia.

Evidence for treatment of lower limb in-stent restenosis with drug eluting balloons.

INTRODUCTION: Restenosis by myointimal hyperplasia after peripheral arterial angioplasty or stenting often limits long term patency. Drug-eluting balloons (DEBs) which inhibit the proliferation of neo-intimal growth of vascular smooth muscle cells may prevent restenosis. The aim of this paper was to examine the evidence in published literature on the use of DEBs in the treatment of peripheral arterial in-stent restenosis (ISR). EVIDENCE ACQUISITION: A systematic literature review was undertaken of all published literature on the treatment of peripheral ISR with drug eluting balloon using Medline and cross-referenced. All published papers on the use of DEBs in peripheral arterial disease (PAD) were used. Cochrane Central Register of Controlled Trials and electronic databases were also searched for on-going studies. EVIDENCE SYNTHESIS: There were no level 1 or 2 evidence published on this subject. The number of high-quality publications is few, and consequently a sufficient analysis is not possible. Recently data from non-randomized cohort studies showed encouraging results with DEB as treatment modality for ISR, whether used alone or as combined strategies. CONCLUSIONS: Evidence from the published literature suggests that DEBs are safe in preventing peripheral ISR. Despite strong corporate pressure for the use of DEBs, there is only circumstantial evidence that this is a useful modality for ISR. Results from on-going studies may allow further meta-analysis for efficiency and cost-effectiveness.

Lumivascular Optical Coherence Tomography-Guided Atherectomy in Recurrent Femoropopliteal Occlusive Diseases Associated with In-Stent Restenosis: Case-Series Report.

Lumivascular optical coherence tomography (OCT) is a novel adjunct in the field of medicine. It offers clear real-time imaging of artery walls before and during endovascular intervention. This study reports our initial experience on the use of lumivascular OCT-guided atherectomy in the management of two patients with recurrent restenosis in their femoropopliteal arteries associated with in-stent restenosis. Endovascular procedures were successful with a Pantheris atherectomy device (Avinger, Redwood City, CA, USA) and drug-eluting balloons. The OCT images clearly distinguished normal anatomy from plaque pathology, were of great advantage in both the accurate diagnosis and treatment of target lesions, and may reduce radiation during the endovascular procedure. However, the price of the device and its need for contrast infusion limit its routine clinical use.