Iliac artery endofibrosis: diagnostic dilemna and treatment options.

BACKGROUND: External iliac artery endofibrosis (EIAE) is an uncommon pathology, predominantly occurring in cyclists, caused by thickening of the external iliac artery intima. Symptoms are exercise-dependent and typically consist of pain, muscle cramps and loss of strength in the affected limb at (sub)maximal effort. As other musculo-skeletal as well as conditional problems might cause similar complaints diagnosis is not always easy or straightforward. CASE SUMMARY AND DISCUSSION: We reviewed four cases of (semi-)professional cyclists referred to our department in 2021 because of suspicion of EIAE. In all symptoms only occurred at (sub)maximal effort. All had lowering of ABI on the affected side at a dynamic stress test on the bike. Imaging using CTA, MRA or dynamic angiogram was abnormal in all patients, showing signs suspicious for endofibrosis but of different kind and at different locations. Open surgical repair was performed in all cases by a procedure tailored to the type of lesion. Two patients were treated by a saphenous vein patch angioplasty, in one patient a shortening of the vessel and end-to-end anastomosis was performed and in the fourth patient a spiral saphenous vein graft bypass was placed. Postoperative course was uneventful and exercise was resumed after four weeks in all patients. CONCLUSION: Correct diagnosis is essential in the treatment of EIAE. A complete and multidisciplinary pathway should be followed to distinguish vascular from non-vascular causes. Correct lesion localization is crucial and besides CTA or MRA, more sophisticated techniques such as dynamic angiography or intravascular ultrasound might be needed.

Meso-Rex shunt using deep femoral vein conduit: first report.

The Meso-Rex shunt (MRS) procedure was first described in 1992 by de VILLE et al. for the treatment of extrahepatic portal vein obstruction (EHPVO) in paediatric liver transplant patients. This technique provides more physiological relief of portal hypertension compared to the porto-systemic shunts, which can lead to long-term complications such as hyperammonaemia and hepato-pulmonary syndrome. Different conduits as autologous and cryopreserved veins or prosthetic grafts have been previously reported. We present herein the first case of a MRS using the autologous deep femoral vein in a 17-year-old female patient affected by EHPVO from unknown reasons.

BRAVISSIMO: 12-month results from a large scale prospective trial.

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Inhibiting connexin channels protects against cryopreservation-induced cell death in human blood vessels.

OBJECTIVES: Cryopreserved blood vessels are being increasingly employed in vascular reconstruction procedures but freezing/thawing is associated with significant cell death that may lead to graft failure. Vascular cells express connexin proteins that form gap junction channels and hemichannels. Gap junction channels directly connect the cytoplasm of adjacent cells and may facilitate the passage of cell death messengers leading to bystander cell death. Two hemichannels form a gap junction channel but these channels are also present as free non-connected hemichannels. Hemichannels are normally closed but may open under stressful conditions and thereby promote cell death. We here investigated whether blocking gap junctions and hemichannels could prevent cell death after cryopreservation. MATERIALS AND METHODS: Inclusion of Gap27, a connexin channel inhibitory peptide, during cryopreservation and thawing of human saphenous veins and femoral arteries was evaluated by terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assays and histological examination. RESULTS: We report that Gap27 significantly reduces cell death in human femoral arteries and saphenous veins when present during cryopreservation/thawing. In particular, smooth muscle cell death was reduced by 73% in arteries and 71% in veins, while endothelial cell death was reduced by 32% in arteries and 51% in veins. CONCLUSIONS: We conclude that inhibiting connexin channels during cryopreservation strongly promotes vascular cell viability.

Treatment of symptomatic mobile aortic thrombus.

BACKGROUND: Mobile thoracic or abdominal aortic thrombi are a potential source of embolism to visceral organs or lower limbs. Detection levels of this type of aortic pathology after any embolic event have increased considerably. Nevertheless, therapeutic management of an intraluminal mobile thrombus of the aorta remains controversial. The aim of this study is to describe the treatment modalities for symptomatic mural aortic thrombi based on three cases diagnosed at our institution and to review the literature. METHODS: During the last decade, several patients with peripheral embolisation were diagnosed with an intraluminal mobile aortic thrombus. Three patients who were treated differently were selected and reviewed. In addition a literature search was performed on PubMed and Medline from their inception to the present for all English language articles using the following keywords: blue toe syndrome, peripheral arterial embolisation, mobile thrombus and aorta. The advantages and drawbacks of medical management, open and endovascular treatment are described. RESULTS: Three particular patients with embolisation due to a floating aortic thrombus were reviewed. The first patient underwent a thoracotomy with replacement of the descending thoracic aorta. Another case was treated successfully by implanting an endovascular stent graft in the descending thoracic aorta. The last patient was treated medically because of the involvement of the visceral vessels. When reviewing the literature, no randomised controlled trials were found but several case reports have described both open and endovascular techniques. No long-term follow up of this rare pathology is available. CONCLUSIONS: In the literature there is no consensus how to treat a symptomatic floating aortic thrombus. This report shows that therapeutic strategies are influenced by the localisation of the thrombus, the co-morbidities of the patient and the physician' s preferences. Endovascular treatment in combination with high dose statins has become the preferred treatment method although long-term data are lacking.

Angioplasty or primary stenting for infrapopliteal lesions: results of a prospective randomized trial.

Excellent results with small stents in coronary arteries have led endovascular therapists to their use in infrapopliteal vessels. However, to date no level I evidence exists to recommend primary stenting over infrapopliteal angioplasty alone. The aim of this randomized single-center trial was to compare their 1-year outcome. A total of 38 limbs in 35 patients with critical limb ischemia were randomized to angioplasty (22 pts) or primary stenting (16 pts). Target lesions were infrapopliteal occluded (36) or stenotic (20) lesions ranging from <2 to >15 cm in length. The mean age was 72 years. At 12 months, there was no statistical difference in survival (angioplasty, 69.3%; primary stenting, 74.7%), in limb salvage (angioplasty, 90%; primary stenting, 91.7%), or in primary and secondary patency (angioplasty, 66 and 79.5%; primary stenting, 56 and 64%) between the groups Renal insufficiency was the only significant negative predicting factor for limb salvage in both groups. In conclusion, the 1-year results for both groups were broadly similar. Stenting has its place in infrapopliteal angioplasty if the procedure is jeopardized by a dissection or recoil, but our results do not support primary stenting in all cases.

A 15-year experience with combined vascular reconstruction and free flap transfer for limb-salvage.

OBJECTIVES: To evaluate the results and complications of combined simultaneous arterial re-vascularisation and free flap transfer in patients with critical limb ischaemia and large soft-tissue defects that would otherwise have required major amputation. DESIGN: Retrospective analysis of all combined procedures performed between 1993 and 2007 with regard to complications and outcome. MATERIALS AND METHODS: Seventy-eight procedures were performed in 76 patients with a mean age of 60 years (range: 18-80 years). The majority had diabetes (70.5%). Follow-up was obtained from hospital charts and telephone contacts with patients or GPs. RESULTS: The limb-salvage rate was 93% after 1 year, 80% after 3 years and 71% after 5 years. Perioperative complications occurred in 50% of the patients; six out of 78 (7.7%) arterial reconstructions and 13 out of 78 (16.7%) flaps had to be revised during the early postoperative period. However, most flaps could be saved by a secondary procedure resulting in an early failure (amputation) rate of 6%. In-hospital mortality was 3.8%. End-stage renal disease was the only factor predicting limb loss. In total, 65% of the patients survived and were able to walk on their reconstructed limb at 1-year follow-up. Combined survival and limb-salvage rates were 85%, 66% and 51% after 1, 3 and 5 years. CONCLUSIONS: Combined arterial re-vascularisation and free flap transfer can be performed safely with acceptable morbidity and mortality and should be considered for every mobile patient with large soft-tissue deficit (>10cm(2)) without end-stage renal disease prior to major amputation.

Antegrade revascularization for chronic mesenteric ischaemia.

OBJECTIVE: to evaluate the short- and long-term results, obtained after open revascularization for chronic mesenteric ischaemia as a reference in a field with growing interest for PTA and stenting. MATERIALS AND METHODS: we reviewed 14 patients with 15 antegrade revascularizations for chronic intestinal ischaemia, between 1996 and 2003: ten bypasses either to the celiac trunk or to the mesenteric artery and five bifurcated bypasses to both arteries were performed. There was one reimplantation for Wilki syndrome. Graft patency was monitored for a mean period of 24 months (range 1-84 months) by clinical examination and duplex scanning. MAIN RESULTS: one patient had recurrence of symptoms that disappeared after successful reoperation. There was one perioperative death All the other patients (84%) had a long-term symptom free survival. CONCLUSION: antegrade mesenterial revascularization through an upper abdominal approach is an excellent technique with good long-term results. It sets a high standard that will be difficult to obtain with mesenteric PTA and stenting. It remains the preferred method of revascularization in low-risk patients.

[Treatment of iatrogenic femoral pseudoaneurysms by ultrasound-guided percutaneous thrombin injection: effectiveness and complications]. / Behandeling van iatrogene femorale pseudoaneurysmata door middel van echogeleide percutane trombine-injectie: doeltreffendheid en complicaties.

AIM: We retrospectively assessed the effectiveness of ultrasound-guided percutaneous thrombin injection in the treatment of iatrogenic femoral pseudoaneurysms and registered the occurrence of complications in the systemic circulation. METHODS: We performed ultrasound-guided thrombin injection in 26 iatrogenic femoral pseudoaneurysms: 24 were classified as single en 2 as complex. We registered the volume and the pseudoaneurysm neck measurements, as well as the complication rate. RESULTS: Ultrasound-guided percutaneous thrombin injection led to a successful obliteration of pseudoaneurysm in 25 out of 26 cases (96.2%). The thrombin amount varied between 250 and 1000 IU. A thrombosis of the common femoral artery after the thrombin injection occurred only in one patient. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is effective and safe in the treatment of iatrogenic femoral pseudoaneurysms provided the exclusion criteria are respected. Complications are rare.

Endovascular repair of aortic rupture.

OBJECTIVES: To report a single centre experience with endovascular repair of ruptures of the descending thoracic and abdominal aorta. DESIGN: Retrospective non-randomised study in a university hospital. MATERIAL AND METHODS: Between February 1997 and October 2002, endovascular repair of the aorta was performed on 125 occasions. In 20 cases, this was done as an emergency (nine ruptured infrarenal aortic aneurysms and 11 descending thoracic aortic ruptures). All patients underwent spiral computed tomographic angiography to assess the feasibility of endovascular repair and the size of the endoprosthesis. RESULTS: Endovascular repair was successfully completed in all patients. Primary conversion to open repair was not necessary. Postoperative 30-day mortality was 5/20 (25%). There were major complications in 12/20 patients. No ruptures of the aneurysms occurred postoperatively. No primary endoleaks occurred, but in 4/20 (20%) secondary surgical interventions were required after a median follow-up of 12 months (range 1-42 months). CONCLUSION: Our early experience shows the feasibility of this technique with early results that compare favourably to those of emergency open repair. Further studies are required to assess the long-term efficacy.

How to perform a below-knee amputation.

Even though modern techniques have improved patient survival and limb salvage rates in patients with critical limb ischaemia and end-stage vascular disease, amputation is sometimes the only possible treatment. In younger patients with traumatic avulsion of a foot, infected gangrene of the foot or a peripheral tumour, amputation is out of discussion and commonly accepted. In older vascular patients, amputation should rather be considered as the starting point for revalidation and rehabilitation than as failure of a revascularization technique. The evolution in prostheses permits a rapid revalidation in most patients. However, an accurate amputation technique is still required to produce a good quality stump allowing early fitting of prosthetics.

Cost-benefit analysis of endovascular versus open abdominal aortic aneurysm treatment.

OBJECTIVE: To compare the costs and benefits of open versus endovascular repair of abdominal aortic aneurysm (AAA). METHODS: A consecutive series of 29 elective patients (open treatment, N = 20 and endovascular treatment, N = 9) were compared retrospectively. RESULTS: Operating time was significantly shorter for endovascular treatment (mean 90 vs. 125 min, p = 0.026). No endovascular procedure was converted to open surgery; one early endoleak was seen which sealed spontaneously. Endovascular treatment resulted in a shorter ICU and hospital stay (0 days vs. 2 days, p. 0.001 and 5 days vs. 11 days, p = 0.01 respectively). Mean total cost did not differ 361,938 BEF (9,048 Euro) vs. 382,995 BEF (9,575 Euro), p = 0.46. Endovascular treatment generated significantly less hospitalization costs (73,162 BEF or 1,829 Euro vs. 18,2740 BEF or 4,568 Euro, p = 0.001) but required a more expensive implant (153,293 BEF or 3,832 Euro vs. 38,296 BEF or 957 Euro, p = 0.001). Mean total cost for the patient was significantly higher in the endovascular treatment group (66,309 BEF or 1,658 Euro vs. 24,969 BEF or 624 Euro, p = 0.003). CONCLUSION: Our experience confirms the feasibility and safety of endovascular AAA treatment. It is associated with a shorter ICU and hospital stay and less morbidity. Overall cost for society does not differ significantly as the benefit, of lower hospitalization costs is undone by the high cost of the endovascular graft.

[A case of open bite]. / Su un caso di morso aperto.

The Authors describe the classification of the malocclusion by Angle, and considerate one open byte case, may be caused by extrusion of first lower right molar, describing orthodontic treatment for his correction.