Training of vascular surgeons by interventional radiologists.

This paper will discuss the potential role of interventional radiologists in teaching of endovascular skills to vascular surgical trainees. Prerequisites and advantages of such a training will be discussed, as well as the secondary effect this kind of training program may have on developing multidisciplinary teams.

From puncture to closure of the common femoral artery in endovascular aortic repair.

In all fields of surgery there is a trend towards less invasive procedures reducing hospital stay, complications and mortality. Open surgery in the treatment of aortic diseases is gradually less applied, and instead endovascular aortic repair - EVAR - is a widely accepted treatment modality of today. The traditional approach in EVAR involves surgical exposure of the femoral arteries with bilateral groin incisions. Through the groin access, and under fluoroscopy, a special insertion sheath introducer is used to position a stent graft in the desired location with the patient in general or epidural anesthesia. The evolving stent-technology with smaller sheath sizes has broadened the scenario for alternative approaches for access and closure of the common femoral arteries. The following review presents an introduction on technical aspects of puncture of the femoral artery and closure of the arterial wall using percutaneous closure devices. We also aim to discuss three important approaches to expose and close the femoral arteries during endovascular aortic repair: The cut down approach, the true percutaneous technique, and the femoral fascial closure. Finally, factors important in the choice of techniques will be discussed in relation to early and late complications. We suggest that a percutaneous femoral approach should initially be considered for all endovascular aortic procedures, but with a low threshold to convert to traditional cut-down technique when complications such as bleeding, stenosis, ischemia, or femoral artery injury occur. The choice of the optimal femoral approach depends on the unique anatomy of each patient.

The role of vena cava filters in the management of venous thromboembolism.

This paper will deal with the role of vena cava filters in the management of venous thromboembolism. The role of medical therapy, indications and contraindications for the placement of caval filters will be discussed. An overview of the currently available filters will be given, and technical aspects, as well as complications related to the procedure will be discussed. Finally the management of patients with a filter in situ and indications for caval filter removal shall be dealt with.

The surgical and endovascular management of deep venous thrombosis of the lower extremity.

This paper will discuss the clinical sequelae of deep venous thrombosis of the lower extremity and will deal briefly with conservative therapy. The (endo)vascular modalities that are currently used will be described more in detail, and includes systemic thrombolysis, surgical thrombectomy, catheter directed thrombolysis and other catheter based therapies like ultrasound assisted thrombolysis, pharmacomechanical thrombolysis and percutaneous mechanical thrombectomy. Results, advantages and disadvantages of each technique will be dealt with.

Determinants of haemodialysis access survival.

BACKGROUND: Vascular access patency is of vital importance for patients requiring haemodialysis. This analysis validates potential risk factors and benefits in patients undergoing vascular access procedures. PATIENTS AND METHODS: Vascular access procedures performed over a two-year period were retrospectively analysed. Clinical data and concomitant medication were retrieved from files as were surgical data following a standardized data capture sheet. Outcome parameters were primary (PP) and secondary patency (SP) as well as freedom from repeated revascularization. Minimal follow-up with functioning access was 679 days. RESULTS: During the observation period, 244 patients (mean age 62.2 +/- 0.9 years, 60.7 % male patients, 36.1 % pre-emptive, 31.1 % late referral) underwent vascular accesses procedures. PP and SP were 35.6 % and 45.6 %, respectively, at 540 days. Presence of diabetes mellitus was associated with decreased PP (OR: 0.6, 95 %-CI: 0.3 - 1.0) and SP (OR: 0.4, 95 %-CI: 0.2 - 0.7), whereas female gender was associated with lower SP (OR: 0.6, 95 %-CI: 0.3 - 0.9) and freedom from repeated revascularization rates (OR: 0.6, 95 %-CI: 0.3 - 1.0). In contrast, presence of hyperparathyreoidism was associated with higher SP (OR: 1.7, 95 %-CI: 1.0 - 3.0) and freedom from repeated revascularization (OR: 1.7, 95 %-CI: 1.0 - 3.0) rates. CONCLUSIONS: Haemodialysis access performs worst in patients with diabetes mellitus and in women. The benefit of hyperparathyroidism should be interpreted as hypothesis generating.

Endovascular aneurysm repair: state-of-art imaging techniques for preoperative planning and surveillance.

Endovascular aneurysm repair (EVAR) represents one of the greatest advances in vascular surgery over the past 50 years. In contrast to conventional aneurysm repair, EVAR requires accurate preoperative imaging and stringent postoperative surveillance. Duplex ultrasound (DUS), transesophageal echocardiography, intravascular ultrasound, computed tomography (CT) and magnetic resonance (MR), each provide useful information for patient selection, choice of endograft type and surveillance. Today most interventionists and surgeons will rely on CT or MR to assess aortic morphology, evaluate access artery patency and locate side branch orifices. However, recent developments in cross-sectional imaging, including advanced image postprocessing, multi-modality image fusion and new contrast agents have resulted in improved spatial resolution for preoperative planning. Advanced reconstruction algorithms, like dynamic CTA and MRA, provide valuable information on dynamic changes in aneurysm morphology that might have an important impact on endograft selection. During follow-up, imaging of the graft and aneurysm is of utmost importance to identify patients in need of secondary intervention. This has led to rigorous follow-up protocols including duplex ultrasound and regular CT examinations. The use of these intense follow-up protocols has recently been questioned because of high radiation dose and the frequent use of nephrotoxic contrast agents. New imaging modalities like contrast enhanced DUS, dynamic MR and dual-source CT could reduce radiation dose and obviate the need for nephrotoxic contrast. Up-to-date knowledge of non-invasive vascular imaging and image processing is crucial for EVAR planning and is essential for the development of follow-up programs involving reduced risk of harmful side effects.

Neuro-rescue during carotid stenting.

This paper deals with the treatment of acute neurological complications that may occur during carotid angioplasty with stenting. Endovascular 'neurorescue' techniques include mechanical thrombus removal (using retrieval devices, aspiration catheters, and wire or balloon fragmentation) and local and intra-arterial thrombolysis. The treatment of acute thrombosis and dissection during carotid artery and stenting will also be discussed. Knowledge of these additional skills is essential to increasing the safety of carotid stenting procedures.

A new surgical approach for exclusion of renal artery aneurysms avoiding organ ischemia.

INTRODUCTION: Surgical treatment of renal artery aneurysms is inevitably associated with temporary renal artery occlusion and risk of ischemic injury. We present a technique for renal artery grafting and aneurysm exclusion without interrupting renal blood flow. REPORT: A symptomatic renal artery aneurysm was bypassed with a venous graft between the abdominal aorta and the very distal renal artery utilizing a distal anastomotic device without interruption of renal blood flow. The aneurysm was then excluded by means of hemostatic clips. CONCLUSION: The presented surgical technique offers the major advantage of avoiding organ ischemia and accelerating the surgical procedure.

Dealing with complications related to carotid artery stenting.

This paper will describe the complications that can occur during and after carotid artery angioplasty and stenting. Etiology, prevention and treatment of procedure related complications will be dealt with.

A close look at closure devices.

This paper will deal with the use of arterial closure devices after endovascular procedures. An overview of the currently available devices will be given. Indications and contraindications for their use, results and complications will be described.

Atherectomy in complex infrainguinal lesions: a review.

In the femoropopliteal segment, endovascular revascularization techniques have gained the role as a first line treatment strategy. Nitinol stent placement has improved the short- and mid-term primary patency rates in most lesion types and is therefore widely applied. Stenting has several shortcomings as in-stent restenosis, stent fractures and foreign material being left behind in the vessel. The concept of atherectomy is plaque debulking. This results in a potential reduction of inflation pressure requirements in angioplasty. Stent placement and consecutive in-stent restenosis may be avoided. In this non systematic literature review, the performance of different atherectomy techniques, such as direct atherectomy, orbital atherectomy, laser debulking and rotational atherectomy in the treatment of complex femoropopliteal lesions, including long lesions, moderately to heavily calcified lesions as well as occlusions and in-stent restenosis, has been analyzed.

Endovascular treatment of extracranial carotid artery aneurysms.

The objective of this article was to give a comprehensive overview over the different etiologies and the current techniques and results of endovascular treatment of aneurysms of the extracranial carotid artery. Extracranial carotid artery aneurysms are characterized by a low incidence but a high stroke rate in case of conservative management. Open surgical treatment has the disadvantage of a high percentage of postoperative cranial nerve injury and morbidity due to the cervical exposure. Endovascular treatment is attractive because of its less invasiveness. Due to the large variety of etiologies and different endovascular treatment approaches no comparative trials or even large retrospective studies do exist to determine the optimal treatment for the disease. This is a non-systematic review of clinical case series and retrospective analysis about endovascular treatment of extracranial carotid artery aneurysms in English literature.

Preoperative and postoperative assessment of laparoscopic inguinal hernia repair by dynamic MRI.

RATIONALE AND OBJECTIVES: To determine the value of dynamic MRI for seroma detection, hernia recurrence, and mesh placement in patients after laparoscopic inguinal hernia repair. METHODS: Thirteen inguinal hernias in 10 consecutive patients were evaluated before and after surgery by using an MRI protocol consisting of coronal T1-weighted (fast field echo) and T2-weighted (turbo spin-echo) images and two sequences obtained during straining (turbo field echo gradient technique). All patients underwent a transabdominal preperitoneal laparoscopic inguinal hernia repair. MRI scans were reviewed for the presence of postoperative fluid collections, recurrent hernia, and mesh localization. RESULTS: In all patients, an inguinal hernia was identified on the preoperative MRI and was absent on the postoperative MRI. In all patients treated laparoscopically, the mesh and its position were clearly identified. Three small fluid collections were found on the postoperative MRI scans. CONCLUSIONS: Dynamic MRI can demonstrate small, postoperative fluid collections and a sufficient hernioplasty by showing the proper position of the mesh and the absence of a hernia.

Dynamic magnetic resonance imaging in the diagnosis of groin hernia.

RATIONALE AND OBJECTIVES: The authors determine the feasibility of dynamic magnetic resonance (MR) imaging in the diagnosis of groin hernia. METHODS: Ten volunteers and 10 patients with clinically evident and surgically proven herniations were evaluated using T1-, and T2-weighted sequences and two dynamic sequences. The visibility of anatomic structures that are crucial for the assessment and the differentiation of inguinofemoral herniations was evaluated. RESULTS: The inguinal rings could be identified in all subjects. The inferior epigastric vessels could be identified in 85%. In 10 patients, 11 hernias were found at MR imaging, whereas at surgery and physical examination 13 herniations were diagnosed (84.6%). The two hernias that were missed initially could be identified retrospectively on MR imaging. One volunteer showed a small bilateral inguinal hernia on MR imaging that could be confirmed on physical examination. CONCLUSIONS: The anatomic structures that are crucial for the assessment and the differentiation of inguinofemoral herniations can be identified prospectively with MR imaging.

Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings.

OBJECTIVE: To determine the diagnostic accuracy of physical examination, ultrasound, and dynamic MRI in patients with inguinal hernia. METHODS: In 41 patients with clinically evident herniations, 82 groins were evaluated using a standard ultrasound and MRI protocol, the latter including T1- and T2-weighted sequences as well as two dynamic sequences. All ultrasound examinations and MRI scans were reviewed without knowledge of clinical findings. In all cases, correlation with findings at laparoscopic surgery was made. RESULTS: At surgery, 55 inguinal herniations were found. Physical examination revealed 42 herniations (one false-positive finding), whereas ultrasound made the diagnosis of a hernia in 56 cases (five false-positive and four false-negative findings). MRI diagnosed 53 herniations (one false-positive and three false-negative findings). Thus, sensitivity and specificity figures were 74.5% and 96.3% for physical examination, 92.7% and 81.5% for ultrasound, and 94.5% and 96.3% for MRI. CONCLUSIONS: In patients with clinically uncertain herniations, MRI is a valid diagnostic tool with a high positive predictive value.

Malignant stromal tumour of the rectum: findings at endorectal ultrasound and MRI.

This case report describes the findings on endorectal ultrasound and MRI in a patient with a giant malignant stromal tumour of the rectum. A review of imaging characteristics and histopathological findings as described in the literature is presented.

Case report: bronchial to coronary artery anastomosis--a potential hazard in bronchial artery embolization.

Bronchial artery embolization is a well-established treatment for patients with haemoptysis. Communications between coronary and bronchial vessels have been seen on coronary angiography. This report describes a case of a bronchial to coronary artery anastomosis diagnosed prior to embolization in a patient with haemoptysis.

Airport and superficial femoral artery obstruction due to a wandering coronary stent: the possibility of airport detection of modern implant metals.

In the treatment of coronary artery disease, peripheral loss of a coronary stent is an unusual complication. We present the case of a patient who suggested that his right leg claudication was caused by a slipped coronary stent 2 years previously. The patient was convinced about this unusual finding based on an airport security check. Examination proved him to be right. However, the ability to detect an object using eddy currents is dependent on the object's permeability and its conductivity. Ferrous (iron) content is not the critical factor. Modern implant materials and processing techniques result in implants that are difficult to magnetize i.e. their permeability is very low. In addition their conductivity is very low. This enables modern implants to escape detection at airports. For this reason the event at the airport, as described by our patient, is considered coincidental.