Safety of early endarterectomy in patients with symptomatic carotid artery stenosis: an international multicenter study.

BACKGROUND AND PURPOSE: Although the latest recommendations suggest that carotid endarterectomy (CEA) should be performed in symptomatic carotid artery stenosis (sCAS) patients within 2 weeks of the index event, only a minority of patients undergo surgery within the recommended time-frame. The aim of this international multicenter study was to prospectively evaluate the safety of early CEA in patients with sCAS in everyday clinical practice settings. METHODS: Consecutive patients with non-disabling acute ischaemic stroke (AIS) or transient ischaemic attack (TIA) due to sCAS (≥ 70%) underwent early (≤ 14 days) CEA at five tertiary-care stroke centers during a 2-year period. Primary outcome events included stroke, myocardial infarction (MI) or death occurring during the 30-day follow-up period and were defined according to the International Carotid Stenting Study criteria. RESULTS: A total of 165 patients with sCAS [mean age 69 ± 10 years; 69% men; 70% AIS; 6% crescendo TIA; 8% with contralateral internal carotid artery (ICA) occlusion] underwent early CEA (median elapsed time from symptom onset 8 days). Urgent CEA (≤ 2 days) was performed in 20 cases (12%). The primary outcomes of stroke and MI were 4.8% [95% confidence interval (CI) 1.5%-8.1%] and 0.6% (95% CI 0%-1.8%). The combined outcome event of non-fatal stroke, non-fatal MI or death was 5.5% (95% CI 2.0%-9.0%). Crescendo TIA, contralateral ICA occlusion and urgent CEA were not associated (P > 0.2) with a higher 30-day stroke rate. CONCLUSIONS: Our findings indicate that the risk of early CEA in consecutive unselected patients with non-disabling AIS or TIA due to sCAS is acceptable when the procedure is performed within 2 weeks (or even within 2 days) from symptom onset.

New aspects of induction chemotherapy for head and neck cancer: POSTASCO 2011.

Treatment options of patients with advanced head and neck cancer developed in the last years. Surgical approaches with or without radiotherapy used to be the standard therapy for a long time. Calls for organ preservation, poor overall survival and unsatisfactory quality of life made changes in this therapy regime necessary. Systemical approaches were evaluated, first concepts of platinum-based chemotherapy paired with 5-fluorouracil (PF) made up the basis of induction chemotherapy (ICT). Hypothesized advantage of this regime was improvement in local and distant tumor responsiveness with an acceptable toxicity profile. Further investigations proved the addition of docetaxel (TPF) superior to PF, which presents the gold standard of current induction chemotherapy regimes. Long-term results underlining well-known aspects of this regime as well as new approaches of induction chemotherapy were published at ASCO 2011, including the addition of bioimmunotherapy to radiotherapy, adding nanoparticle-bound albumin to chemotherapy and investigations in toxicity reduction. Further investigations are still made not only to increase survival outcomes and local control but also to improve quality of life by reducing acute and late toxicities.

[Evaluation of treatment adaptation for low response to ASA in vascular surgery]. / Evaluation einer Therapieanpassung bei ASS-Low-Response in der Gefäßchirurgie.

BACKGROUND: A decreased antiplatelet prophylaxis (low response, LR/high on-treatment platelet reactivity, HPR) with acetylsalicylic acid (ASA) is associated with an increased risk of thromboembolic events. The prevalence of a LR is frequent with about 20% and a therapeutic regimen is not yet established. The aim of this prospective study was to evaluate the effectiveness of a therapeutic regimen for treatment adaptation when LR/HPR is detected in vascular surgery patients. METHODS: Overall, 36 patients under long-term antiplatelet treatment with 100 mg/day ASA and a detected ASA low response (ALR) were included in the study. In this patient group a modification of the prophylactic medication was carried out according to the established treatment plan and a control aggregometry was performed. The therapeutic regimen followed the test and treat principle. To evaluate the effect of ASA impedance, aggregometry with multiple electrodes was used (multiplate). RESULTS: All 36 patients were successfully transferred to response status with the treatment scheme. In 32 (88.89%) patients an increased dose of 300 mg/day ASA was carried out and in 2 (5.56%) patients the medication was changed from ASA to clopidogrel. A further 2 (5.56%) patients were switched to oral anticoagulation with phenprocoumon, due to other indications. Bleeding complications or other side effects did not occur. CONCLUSION: The chosen treatment regime for a low response proved to be effective and safe in vascular surgery patients. A guideline-compliant increase of the ASA dose from 100 mg to 300 mg/day predominantly led to an effective inhibition of platelet aggregation in the aggregometry.

Oestradiol levels in varicose vein blood of patients with and without pelvic vein incompetence (PVI): diagnostic implications.

PURPOSE: To assess the difference in the oestradiol levels of blood taken from varicose veins in patients with and without pelvic vein incompetence (PVI). MATERIALS AND METHODS: Women of child-bearing age with symptomatic primary or recurrent varicose veins of the great saphenous vein (GSV) were included in a prospective study. Patients underwent duplex ultrasonography and pelvic vein phlebography. They were divided into a group with PVI (PVI group) and a control group with GSV reflux alone (VV group). Blood samples were collected from the GSV at the sapheno-femoral junction or lower in the thigh as well as from the arm. Oestradiol levels were determined by electroluminescence. RESULTS: Between January and December 2007, 40 women were studied, of which 19 showed phlebographic evidence of PVI (PVI group), while 21 were included in the VV group. Phlebography revealed an incompetent ovarian vein in 14 (74%) patients of the PVI group, dilated uterine and ovarian plexuses in 12 (63%) and an incompetent internal iliac vein in six cases (32%). In the PVI group, the median oestradiol level in GSV samples was 121 pgml(-1) (range: 12-4300), while in the VV group the median level was 75 pgml(-1) (range: 9-1177). In the upper limb, the PVI group patients had a median level of 78 pgml(-1) (range: 15-121) and the VV group patients 68 pgml(-1) (range: 13-568). The ratio of lower limb/upper extremity was significantly higher (p<0.002) in patients of PVI group (median: 1.9; range: 0.7-33) than in those of the VV group (median: 1.1; range: 0.8-13). A threshold ratio of 1.4 showed the highest combined sensitivity and specificity in differentiating patients with PVI from those without. CONCLUSIONS: In patients with varicose veins arising from the GSV, oestradiol levels were significantly higher in the lower limb than in the upper extremity in the subgroup with associated PVI. It may be possible to use this observation as a diagnostic test in patients with suspected PVI. This deserves further study.

Long-term results after transfemoral venous thrombectomy for iliofemoral deep venous thrombosis.

OBJECTIVE: In patients presenting with extensive venous thrombosis affecting the pelvic veins, transfemoral venous thrombectomy has been suggested as an effective treatment in selected patients. We present our experience of this technique as well as its long-term results. PATIENTS AND METHODS: Between January 1998 and January 2008, a total of 83 patients underwent transfemoral venous thrombectomy in our Department of Vascular Surgery. In 22 cases, this was combined with angioplasty and stenting of an iliac vein stenosis. Isolated intra-operative thrombolysis was performed in eight cases to treat deep venous thrombosis (DVT) affecting veins distal to the common femoral vein. All patients suffered from a DVT involving the pelvic veins. A DVT involving all venous segments from the pelvis to the calf was present in 63% of cases. Patients were followed up at 3 months, 6 months and yearly thereafter by clinical and duplex ultrasound examination. RESULTS: In all patients, the procedure was successful in achieving re-canalisation of the pelvic veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Life-table analysis showed that, after a mean duration of 60 months following treatment, approximately 75% of the treated venous segments remained patent. Moderate post-thrombotic syndrome (PTS; clinical severity, etiology, anatomy and pathophysiology (CEAP) C2-C4) was present in 20% of cases; severe PTS (CEAP C5 and C6) did not occur in any of the treated patients. CONCLUSIONS: It is safe and effective to treat extensive iliofemoral DVT using transfemoral venous thrombectomy and this prevents the development of severe PTS in the long term. The procedure is only feasible in a subset of patients with DVT, depending on the extent and the age of the thrombosis.

[The current value of induction chemotherapy. ASCO Congress 2010]. / Aktueller Stellenwert der Induktionschemotherapie. ASCO-Kongress 2010.

The aim of systemic induction chemotherapy is organ preservation and tumor downstaging to improve resectability and reduce surgical risk. Not only the prolongation of overall survival but also the entitlement to a better quality of life during the treatment of patients with head and neck squamous cell cancer (HNSCC) have made changes to current treatment regimes necessary. Disappointing results prevented the breakthrough of PF therapy (cisplatin and 5-fluorouracil, 5-FU). New approaches using docetaxel, cisplatin and 5-FU (TPF) as a triple combination as well as the additional extension of novel biological targets within study designs are cause for fresh hope. Thus, the TPF combination has been established as the standard induction chemotherapy regime.

Pelvic venous incompetence: reflux patterns and treatment results.

OBJECTIVE: To assess reflux patterns and the results of endovascular obliteration of ovarian veins in patients with symptomatic pelvic venous incompetence (PVI). METHODS: A total of 71 female patients (mean age 49 years) with signs of PVI on selective phlebography of the pelvic veins were included in the study. In 53 cases (75%), recurrent varicose veins following previous surgery and stripping of the great saphenous vein were present and 51 patients (72%) were multiparous (> or = 2 children). Symptoms were scored on a visual analogue scale (VAS) assessing pelvic and lower limb pain. After duplex ultrasonography of the lower limb veins, in cases of suspected PVI, the presence of any reflux in the ovarian and pelvic veins was demonstrated by phlebography. In selected cases, endovascular treatment with embolisation was used. Follow-up assessment of symptoms was carried out at 1, 2 and 3 years. RESULTS: The left ovarian vein (OV) and the right internal iliac vein (IIV) were most frequently affected by reflux (n=41, 58% each). In about half the number of patients, reflux was demonstrated in more than one of the main pelvic veins (n=38, 54%). An extension of reflux into varicose veins of the groin or lower limb was demonstrated in 44 patients (62%); 35 patients (49%) received treatment for their PVI by coil embolisation. Fifty-five patients (77%) completed follow-up. Patients with isolated ovarian vein incompetence, who were treated by embolisation, experienced a significant improvement of symptoms (mean symptom score 5.2 standard deviation (SD) 3.5 before and 1.2 SD 0.9 after embolisation treatment; p<0.0001), while patients with untreated incompetence did not show improvement in symptoms (mean score 4.5 SD 1.6 before and 5.1 SD 1.5 after conservative treatment; non-significant (N.S.)). Improved symptoms were detected in patients with isolated IIV incompetence, who underwent embolisation treatment (mean symptom score 5.1 SD 2.5 before and 2.1 SD 1.6 after treatment; N.S.) although this did not reach statistical significance. Conservative treatment of patients with isolated IIV incompetence resulted in no relevant changes (mean score 4.2 SD 2.0 before and 4.5 SD 2.1 after treatment; N.S.). Worsening of symptoms was found in patients with combined reflux who underwent conservative treatment (mean score 5.3 SD 2.0 before and 6.5 SD 2.5 after treatment, N.S.). In case of combined OV and IIV reflux, isolated interventional treatment of incompetent ovarian veins did not improve symptoms at each interval of the follow-up (mean score 5.2 SD 2.1 before and 5.1 SD 2.6 after treatment, N.S.), while coiling of all reflux pathways resulted in symptom reduction; but this did not reach statistical significance due to the small numbers of patients (mean score 5.6 SD 2.2 before and 3.2 SD 2.1 after treatment, N.S.). CONCLUSIONS: Combined reflux in more than one pelvic vein is common. In these cases, isolated treatment of ovarian veins or conservative treatment is associated with a poor midterm clinical outcome. A clinical improvement was achieved only in patients with isolated ovarian vein incompetence.

Salvage of a dialysis angioaccess by bypassing a central venous obstruction to the common femoral vein.

We describe the case of a 71 year-old male patient undergoing haemodialysis who presented with severe symptoms of venous hypertension at the left upper extremity due to subclavian and innominate vein obstruction. The patient had a well functioning ispilateral angioaccess. The pain and disabling swelling of the upper extremity developed 12 months after having a radio-cephalic arteriovenous fistula performed and progressively worsened in the last two months. The patient underwent extraanatomic axillo-femoral venous bypass grafting with a 8 mm polytetrafluoroethylene graft to the ispilateral common femoral vein. The postoperative recovery was regular and the patient was discharged 6 days after surgery with a functioning bypass and relief from the venous hypertension symptoms. In this case, surgical bypassing of a central venous obstruction through an extra-anatomical pathway relieved the symptoms of venous hypertension and prolonged the use of the haemodialysis access.

MR venography in the detection of pelvic venous congestion.

PURPOSE: To investigate the feasibility of using magnetic resonance venography (MRV) to detect pelvic venous congestion (PVC). METHODS: A prospective study of 23 female patients with signs and symptoms of PVC, who underwent duplex sonography, MRV and phlebography (P). Examinations were interpreted in a blinded fashion. Visualization of venous anatomy, presence of venous incompetence and congestion grade were evaluated. Sensitivity and specificity of MRV using P as reference were calculated. RESULTS: MRV agreed with P in 96% (Cohen-K-value 0.646) and in 70% (K 0.555) of the cases respectively in the venous anatomy and congestion grade. Sensitivity and specificity of MRV were 88% and 67% for ovarian veins, 100% and 38% for hypogastric veins and 91% and 42% for the pelvic plexus. CONCLUSIONS: In this prospective study MRV showed high sensitivity in the evaluation of patients with suspected PVC. Routine use of this diagnostic method requires further studies in larger patient cohorts.

Residual stumps associated with inguinal varicose vein recurrences: a multicenter study.

PURPOSE: It is unclear whether a residual sapheno-femoral stump left in place after stripping of the great saphenous vein can contribute to the formation of late inguinal varicose vein recurrence. In order to obtain information about the time course of recurrence development, patients with histologically proven residual stumps were recruited and asked about the interval between the initial operation and the first clinical signs of varicose vein recurrence. METHODS: A multi-centre study involving 7 centres was conducted amongst patients undergoing redo-surgery for inguinal varicose vein recurrences. The sapheno-femoral stumps resected during the redo-surgery were classified histologically. Patients with a proven long residual sapheno-femoral stump were asked to describe the first signs of varicose vein recurrence with the help of a standardised questionnaire. From these data the symptom-free interval, consisting of the time frame between the initial operation and the first signs of recurrence, was determined. RESULTS: In 279 legs of 251 patients a long residual sapheno-femoral stump was present. Most patients had experienced a symptom-free interval after the initial operation with a mean duration of 7.4 S.D. 5.5 years. Recurrent varicose veins became apparent after a mean time interval of 6.3 S.D. 5.3 years and congestion symptoms occurred after a mean interval of 8.5 S.D. 5.7 years. CONCLUSIONS: In patients with symptomatic groin recurrences, a long residual sapheno-femoral stump was found in about two thirds of cases. The first clinical signs of varicose vein recurrence can be expected 7-8 years after the initial treatment at the earliest. Long term follow up is required reliably to asses the outcome of treatment for varicose veins.

Acute iliofemoral deep venous thrombosis due to giant ovarian tumor: report of a hybrid treatment.

Ovarian tumors rarely cause acute iliofemoral thrombosis due to direct compression. This case represents an example of successful therapy using an interdisciplinary approach. A 37-year-old woman was admitted with a painful swelling of the left lower limb. Computed tomography revealed a giant abdominal mass originating from the left ovary producing a thrombotic occlusion of the left iliofemoral veins. Surgical treatment consisted of complete tumor removal, adnexectomy and appendectomy. During the same operation, transfemoral thrombectomy and stent implantation in the iliac vein were performed, followed by creation of an arteriovenous fistula in the left groin. Hystologic examination revealed a well-differentiated mucinous ovarian adenocarcinoma. The patient recovered well and is tumor-free 6 months after surgery. The deep venous system is still patent at follow-up. In this case, minimal surgical trauma and complete tumor as well as thrombus removal succeeded through a positive complementary interdisciplinary approach.

Deep venous thrombosis in a patient with large uterine myomata. Case report.

A 42-year-old woman was admitted with a painful swelling of the left lower limb. Computed tomography revealed an inhomogenous uterine enlargement due to multiple myomata producing a thrombotic occlusion of the left iliac veins. Surgical treatment consisted of isolated hysterectomy. During the same operation, transfemoral thrombectomy and stent implantation in the iliac vein were performed. Hysto-logic examination revealed numerous leiomyomata as well as an endometriosis. The patient recovered well and is pain-free six months after surgery. The deep venous system is still patent at follow-up. Uterine myomata rarely cause acute iliac vein thrombosis due to direct compression. This case represents an example of successful therapy using an interdisciplinary approach.

Is initial success of thrombolytic therapy with rt-PA in patients with lower limb ischemia durable? A long-term follow-up series.

BACKGROUND: Catheter-directed intraarterial thrombolytic therapy with rt-PA has been established as an alternative to surgery in selected patients with lower limb ischemia. The purpose of this study is to evaluate its long-term results and to try to identify patient variables influencing outcome. PATIENTS AND METHODS: The results of thrombolytic treatment for acute or subacute lower limb ischemia in 82 patients (51 male, 31 female) were retrospectively analysed. Clinical data (time of symptoms onset, clinical stage, type of affected vessel, anatomical localisation) as well as comorbidities were recorded. The success rate of thrombolysis as well as the incidence of adverse events was evaluated. Patients with initial success were followed up after a median of 52,5 months. RESULTS: Thrombolytic therapy was successful in 67 cases (82%). An additional endovascular or surgical procedure was necessary in 39 of these patients (48%). The overall bleeding rate was 18% and the mortality and major amputation rate was 1%. 42 patients with early clinical success were available for follow-up. 34 of them (81%) were free of ischemic symptoms and the overall limb salvage rate was 96%. We could not identify factors significantly influencing early or long-term results, although there was a trend towards better results in patients with acute ischemia and in patients with occluded native arteries. CONCLUSIONS: Intraarterial local thrombolytic therapy has a relatively high initial success rate in selected patients with lower limb ischemia, but is associated with a significant number of bleeding complications. Furthermore, additional procedures are required in almost half the patients. Initial success is durable at the long-term in the majority of cases. Better selection of patients and refinements of the thrombolytic therapy might help to further improve results and lower the bleeding complications.

Distal revascularization-interval ligation for the treatment of angioaccess-induced ischemia. Case report.

Two cases of upper extremity ischemia due to a steal phenomenon occurring after the creation of an arterio-venous fistula (AVF) for hemodialysis access are described. A successful treatment with a brachial to brachial artery vein bypass and a ligation of the artery distal to the AVF origin (DRIL-Procedure) was performed in both cases. Complete disappearance of symptoms and healing of the ischemic lesions with maintaining of the angioaccess patency 6 months after the repair reveal that this procedure corrected the stealing.

[Prevalence of acetylsalicylic acid (ASA) - low response in vascular surgery]. / Prävalenz der ASS-Low-Response in der Gefäßchirurgie.

BACKGROUND: Research has revealed that a decreased antiplatelet effect (low response [LR]/high on-treatment platelet reactivity [HPR]) of acetylsalicylic acid (ASA) and clopidogrel is associated with an increased risk of thromboembolic events. There are extensive ASA low response (ALR) and clopidogrel low response (CLR) prevalence data in the literature, but there are only a few studies concerning vascular surgical patients. The aim of this study was to examine the prevalence and risk factors of ALR and CLR in vascular surgical patients. MATERIALS AND METHODS: We examined n = 154 patients with an antiplatelet long-term therapy, who were treated due to peripheral artery occlusive disease (PAD) and/or arteria carotis interna stenosis (CVD). To detect an ALR or CLR, we examined full blood probes with impedance aggregometry (ChronoLog® Aggregometer model 590). Risk factors were examined by acquisition of concomitant disease, severity of vascular disease, laboratory test results and medication. RESULTS: We found a prevalence of 19.3 % in the ALR group and of 21.1 % in the CLR group. Risk factors for ALR were an increased platelet and leucocyte count and co-medication with pantoprazole. We found no significant risk factors for a decreased antiplatelet effect of clopidogrel treatment. CONCLUSION: The investigated prevalence for ALR and CLR are in the range of other studies, particularly based on cardiological patients. More investigations are needed to gain a better evaluation of the risk factors for HPR and to develop an effective antiplatelet therapy regime to prevent cardiovascular complications.

[Recanalisation therapy of deep leg and pelvic vein thrombosis]. / Rekanalisierende Therapie der tiefen Bein-/Beckenvenenthrombose.

The conservative treatment of deep leg and pelvic vein thrombosis leads to permanent damage of recanalised veins, which in cases of long distance clots as well as involvement of the pelvic level, increase the risk of developing a postthrombotic syndrome. Such subsequent damage of the deep veins can only be avoided if occluded veins are rapidly recanalised and the function of the valves is successfully reestablished. Recanalisation may consist of surgical, fibrolytic and interventional methods and aims to minimize any subsequent damage; however no potential benefit of recanalisation versus standard treatment has yet been proven by means of methodologically adequate comparative studies. Thus, the indications for recanalisation must remain strict and be founded on a thorough risk-benefit assessment.

Newly designed retraction devices for intestine control during laparoscopic aortic surgery: a comparative study in an animal model.

BACKGROUND: Recent clinical studies have demonstrated the feasibility of laparoscopic surgery for aortic occlusive and aneurysmal disease. However, transperitoneal aortic access is compromised by poor exposure in the operative field from uncontrolled bowel. The retractors that are currently available are inadequate for this task. The development of new retractors would help to facilitate laparoscopic aortic surgery. METHODS: Six female piglets (28-30 kg) in each group underwent laparoscopy with pneumoperitoneum (12 mmHg). Exposure of the infrarenal aorta and cross-clamping were undertaken through a transperitoneal approach. Two paddles inserted in a polyester bilayer (mobile device, group A) or a mesh net fixed to the abdominal wall (fixed device, group B) were used to retain the bowel. Aortotomy and suturing were performed to mimic a vascular procedure. After bleeding was controlled, the intraabdominal pressure (IAP) was lowered to 6 mmHg, and retraction was assessed for 30 min. The main outcome measures were time to deploy the retractors, time to perform the vascular procedure, time to withdraw the devices, and total procedural time. Blood loss and frequency of retraction failure were also recorded. RESULTS: Mean time to deploy the device was 22 +/- 12 min in group A and 36 +/- 34 min in group B (n.s.). Vascular surgery time averaged 60 +/- 24 min in group A and 68 +/- 16 min in group B (n.s.). The times to withdraw the nets were 3.6 +/- 1.2 min and 13.5 +/- 8.2 min, respectively (p < 0.05). Total surgery time was 155 +/- 41 min vs 174 +/- 49 min (n.s.). There were six retraction failures, five in group A and one in group B. When lower IAP was used, there was only one failure in each study group. Mean blood loss was <150 ml in both groups. There were no major complications. CONCLUSIONS: Both methods provided adequate exposure of the infrarenal aorta. Vascular surgery time and blood loss were similar for both groups. The movable device proved more usable and, at lower IAP, more effective. The results of this study demonstrate effective bowel retraction for laparoscopic aortic surgery.