Direct puncture versus contralateral femoral artery approach for catheter-directed thrombolysis of occluded infra-inguinal arterial bypass grafts.

AIM: To compare the safety, effectiveness, and clinical outcome of percutaneous direct puncture approach versus contralateral femoral native vessel approach for catheter-directed thrombolysis of occluded infra-inguinal bypass grafts. MATERIALS AND METHODS: A retrospective analysis was performed comprising a cohort of patients who underwent catheter-directed thrombolysis procedures of occluded infra-inguinal bypass grafts between January 2013 and January 2022, with a follow-up period until June 2022. This included 55 procedures via the native vessel approach and 18 procedures via the direct puncture approach. Primary outcomes were technical success and procedural safety; secondary outcomes included re-intervention rate, limb salvage, and mortality as assessed by log-rank testing and Kaplan-Meier curves. RESULTS: There were no differences between the two groups with regard to patient demographics, except for the number of previous vascular procedures (n=6.83 ± 3.07 direct approach versus n=4.96 ± 2.79 native vessel approach, p=0.025). Thrombolysis was comparably successful in both groups (n=13/18; 72% direct approach versus n=42/55; 76%, p=0.723). There were no differences in the duration of thrombolysis administration. The rate of adverse events was slightly lower in the direct approach group, but without significance (p=0.092). There were no adverse events related to the puncture site in the direct approach group. No differences were found between the time-to-event values for re-occlusion, re-intervention, amputation, or mortality respectively (p=0.662; p=0.520; p=0.816; p=0.462). CONCLUSION: The direct puncture approach seems to be a safe and efficient approach for catheter-directed thrombolysis procedures in infra-inguinal occluded bypass grafts, with clinical outcomes comparable to the native vessel approach.

Paclitaxel drug-coated balloon angioplasty for the treatment of failing arteriovenous fistulas: a single-center experience.

Objectives: To report our experience of angioplasty with Lutonix (Bard Peripheral Vascular, Inc., Tempe, AZ) drug-coated balloon (DCB) for the treatment of failing arteriovenous fistulas (AVF).Materials and methods: Retrospective, single-center analysis consisting of 14 patients treated with Lutonix paclitaxel DCBs in the period from July 2015 through April 2017. We analyzed technical success, clinical success, primary patency of the target lesion, primary patency of the dialysis circuit, and the rate of complications. Regular follow-up of AVF patency was realized by clinical examination and duplex ultrasonography. The Kaplan-Meier survival method was applied to determine the cumulative primary patency of the target lesion and the dialysis circuit.Results: Technical success was 100% and clinical success 92.9%. There were no major or minor complications. Cumulative target lesion primary patency after DCB was 69.2% at 6 months and 31.6% at 12 months. Cumulative vascular circuit primary patency was 61.5% at 6 months and 31.6% at 12 months.Conclusion: Compared to results reported in literature with plain old balloon angioplasty (POBA), Lutonix paclitaxel DCB angioplasty proved a short-term patency benefit in treatment of dialysis AVF stenosis.

Long-term Results of Totally Laparoscopic Aortobifemoral Bypass.

OBJECTIVES: The aim was to estimate the long-term results and patency rates of totally laparoscopic aortobifemoral bypass in aorto-iliac occlusive disease (AIOD). METHODS: All 87 patients who received a laparoscopic aortobifemoral bypass for AIOD on an intention to treat basis between October 2003 and October 2013 were identified. All operations were performed by the same surgical team using a totally laparoscopic technique. Demographic, pre-operative, peri-operative, and follow up variables were collected and analyzed. Patients were followed up at 1 month post-operatively and annually thereafter. Patency rates were calculated in accordance with published patency reporting standards. RESULTS: The median age was 57 years (range 40-78 years). The conversion rate was 20.6% overall. The thirty-day post-operative mortality was 1.1%. Six patients required early re-intervention. There were no graft infections. The median length hospital stay was 6 days (range 4-39 days). The mean follow up was 58.0 months (range 1-133 months). Graft limb based primary, primary assisted, and secondary patency rates were respectively 96.1%, 98.1% and 99.4% at 1 year, and 83.0%, 92.0% and 97.0% at 5 years. CONCLUSION: Totally laparoscopic aortobifemoral bypass is a safe alternative to open surgery in selected patients, with excellent long-term patency rates, albeit at the cost of a steep learning curve.

Possible Familial Presentation in Two Siblings with Carotid Fibromuscular Dysplasia.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease which can affect the cervical, renal and visceral arteries. Here we report on two sisters diagnosed with carotid FMD at the same age, presenting with similar symptoms of pulsating tinnitus. The familial presentation of this rare disorder attracted our attention and was suggestive of a genetic etiology. Conservative treatment with aspirin was initiated. Carotid FMD is a rare disorder of which the exact pathophysiology is not known. A review of the literature on the clinical presentation, diagnosis and management is presented. In addition possible etiological factors and the genetic nature of the disease are discussed.

Possible familial presentation in two siblings with carotid fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease which can affect the cervical, renal and visceral arteries. Here we report on two sisters diagnosed with carotid FMD at the same age, presenting with similar symptoms of pulsating tinnitus. The familial presentation of this rare disorder attracted our attention and was suggestive of a genetic etiology. Conservative treatment with aspirin was initiated. Carotid FMD is a rare disorder of which the exact pathophysiology is not known. A review of the literature on the clinical presentation, diagnosis and management is presented. In addition possible etiological factors and the genetic nature of the disease are discussed.

TEVAR for Ruptured type B Aortic Dissection in a Patient with Turner Syndrome.

TEVAR has replaced open surgical repair as preferred treatment for complicated acute type B aortic dissection. But the literature on thoracic endovascular aortic repair (TEVAR) for ruptured type B dissection is scarce. Patients with Turner syndrome are at risk for aortic dissection and rupture at a young age with an immediate mortality rate of 63%. Only a few cases have been described and the best treatment is not yet established. We present a case of a 49 year-old woman with Turner syndrome who suffered from a ruptured aortic dissection Stanford type B. A TEVAR procedure was performed, but the life of the patient could not be saved. In this case report we discuss the lessons we learned as well as some unsolved questions about TEVAR for ruptured type B aortic dissection.

Effect of clinical examination and anatomical location on native arteriovenous fistula maturation rate in high risk patients.

BACKGROUND: Maximal use of native arteriovenous fistulas (AVFs) for patients on hemodialysis therapy remains a clinical challenge. Primary failure rates remain high with risk factors such as female gender, diabetes mellitus, lower arm AVF and higher age. We wondered if a strategy of careful clinical examination prior to AVF creation and a preference towards an upper arm AVF in case of doubt about the quality of the vein in patients with any of the above mentioned risk factors, would lead to better maturation rates. METHODS: The records of all patients who received an AVF between January 2005 and December 2009 at our University Hospitals Leuven were studied retrospectively. Demographic data, comorbidity, fistula characteristics, fistula maturation and fistula complications were recorded and analyzed. RESULTS: Of 344 patients enrolled, 156 (45.3%) received a lower arm AVF and 188 (54.7%) an upper arm AVF. Two hundred and seventy-six (80.2%) fistulas had a normal maturation. Lower arm AVF was a significant risk factor for non-maturation in this series (73.1% versus 86.2% ; p = 0,0024). Female gender, diabetes and high age were not, but female gender showed a significant difference in distribution in upper arm versus lower arm fistulas (62.40% versus 37.6% ; p = 0,0218). CONCLUSIONS: Careful clinical examination prior to upper or lower arm AVF creation together with the integration of risk assessment in the planning of AVF is worthwhile. A preference towards upper arm fistulas if major risk factors are -present can improve overall maturation rates and lead to the same maturation rates as in the overall dialysis population. Therefore, the presence of risk factors for non-maturation should not lead to the underuse of native AVFs.

Steam ablation versus radiofrequency and laser ablation: an in vivo histological comparative trial.

OBJECTIVE: There is an increasing use of minimal invasive techniques to treat saphenous vein reflux. Among these radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy are frequently used. A new method of thermal ablation is the steam vein sclerosing (SVS) system. This study evaluates the histological changes after ablation of the saphenous veins in goats with RFA, EVLA, and SVS. METHODS: Twelve saphenous veins in six goats were treated with one of the three treatment modalities: four veins with RFA, four with EVLA, four with SVS. Seven days after treatment occlusion and diameter changes were evaluated by ultrasound imaging and histological changes were examined microscopically. RESULTS: Vein length, mean diameter, and the amount of tumescence was comparable between the three groups. Histological examination showed extensive vein wall destruction, the least in the outer layer of the vein wall. The total vein wall damage was 9.2/15 (SD 3.5) for EVLA, 13.3/15 (SD 3.3) for RFA, and 11.2/15 (SD 2.8) for SVS group. There was no significant difference among the three groups. Perivenous tissue damage was low. No extrafascial damage was seen. CONCLUSION: Histological findings after steam ablation are similar to the RFA and EVLA with a low perivenous tissue destruction score and a high vein wall destruction score.

Endovenous laser ablation of the great saphenous vein using a bare fibre versus a tulip fibre: a randomised clinical trial.

OBJECTIVE: This clinical trial aimed to evaluate the clinical results of the use of a tulip fibre versus the use of a bare fibre for endovenous laser ablation. METHODS: In a multicentre prospective randomised trial 174 patients were randomised for the treatment of great saphenous vein reflux. A duplex scan was scheduled 1 month, 6 months and 1 year postoperatively. Ecchymosis was measured on the 5th postoperative day. In addition, pain, analgesics requirement, postoperative quality of life (CIVIQ 2) and patient satisfaction rate were noted. RESULTS: Patients treated with a tulip fibre had significantly less postoperative ecchymosis (0.04 vs. 0.21; p < 0.001) and pain (5th day) (1.00 vs. 2.00; p < 0.001) and had a better postoperative quality of life (27 vs. 32; p = 0.023). There was no difference in analgesic intake (p = 0.11) and patient satisfaction rate (p = 0.564). The total occlusion rate at 1 year was 97.02% and there was no significant difference between the two groups (p = 0.309). CONCLUSION: Using a tulip fibre for EVLA of the great saphenous vein results, when compared with the use of a bare fibre, in equal occlusion rates at 1 year but causes less postoperative ecchymosis and pain and in a better postoperative quality of life.

Laparoscopic versus open approach for aortobifemoral bypass for severe aorto-iliac occlusive disease--a multicentre randomised controlled trial.

OBJECTIVES: To investigate differences between open and laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease on postoperative morbidity and mortality. DESIGN: A multicentre randomised controlled trial. METHODS: Between January 2007 and November 2009, 28 patients with severe aorto-iliac occlusive disease (TASC II C or D) were randomised between laparoscopic and open approach at one community hospital and one university hospital (TASC = Trans-Atlantic Inter-Society Consensus on the Management of Peripheral Arterial Disease). RESULTS: The operation time was longer for the laparoscopic approach (mean 4 h 19 min (2 h 00 min to 6 h 20 min) vs. 3 h 30 min (1 h 42 min to 5 h 11 min); p = 0.101)). Nevertheless, postoperative recovery and in-hospital stay were significantly shorter after laparoscopic surgery. Also oral intake could be restarted earlier (mean 20 h 34 min (6 h 00 min to 26 h 55 min) vs. 43 h 43 min (19 h 40 min to 77 h 30 min); p = 0.00014)) as well as postoperative mobilisation (walking) (mean 46 h 15 min (16 h 07 min to 112 h 40 min) vs. mean 94 h 14 min (66 h 10 min to 127 h 23 min); p = 0.00016)). Length of hospitalisation was shorter (mean 5.5 days (2.5-15) vs. mean 13.0 days (7-45); p = 0.0095)). Visual pain scores and visual discomfort scores were both lower after laparoscopic surgery. Also return to normal daily activities was achieved earlier. There were no major complications in both groups. CONCLUSION: Laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease is a safe procedure with a significant decrease in postoperative morbidity and in-hospital stay and earlier recovery.

Arterioureteral fistula. An unusual cause of aortofemoral bypass infection. A case report.

We report a case of arterioureteral fistula after aortobifemoral bypass surgery and prolonged bilateral double J stents due to ureteral stenosis. A 70-year-old woman presented with a non-tender mass in the left groin and a single episode of haematuria 2 months earlier. A Computed Tomography (CT) revealed a pseudoaneurysm of the left distal suture of the graft. Surgical repair was performed. Because of suspicion of infection the entire aortobifemoral graft was removed and replaced by an autologous venous aortofemoral bypass to the right groin and femorofemoral crossover bypass from the right to the left. During surgery an arterioureteral fistula could be visualized. The urologists performed a left nephroureterectomy of the afunctional left kidney. The further postoperative course was uneventful during the 10 months of follow up.

Stent graft infection in the lower limb.

BACKGROUND: Poor wound healing can occur after limb amputation. CASE REPORT: We describe the case of a patient with a persistent fistula after below-knee amputation. The fistula is maintained due to an infected stent graft. After removal of the stent graft and adequate antibiotic treatment the wounds healed and extended amputation was avoided. CONCLUSION: The diagnosis of stent graft infection is challenging and requires aggressive treatment to prevent further amputation.

Endovenous laser ablation: the role of intraluminal blood.

OBJECTIVE: In this histological study, the role of the intraluminal blood during endovenous laser ablation was assessed. METHODS: In 12 goats, 24 lateral saphenous veins were treated with a 1500-nm diode laser. Four goats were treated in an anti-Trendelenburg position (group 1). The next four goats were treated in a Trendelenburg position (group 2) and the remaining four goats in the Trendelenburg position with additional injection of tumescent liquid (group 3). Postoperatively, the veins were removed after 1 week and sent for histological examination. We measured the number of perforations. Vein wall necrosis and the perivenous tissue destruction were quantified using a graded scale. RESULTS: The 'calculated total vein wall destruction' was significantly higher in the third group (81.83%), as compared with groups one (61.25%) (p < 0.001) and two (65.92%) (p < 0.001). All three groups showed a significant difference in the perivenous tissue destruction scale (p < 0.001) with the lowest score occurring in the third group. Vein wall perforations were significantly more frequent in groups one and two as compared with the third group (T-test respectively p < 0.001, p = 0.02). CONCLUSION: A higher intraluminal blood volume results in reduced total vein wall destruction. Injection of tumescent liquid prevents the perivenous tissue destruction and minimises the number of perforations.

Does medical specialty influence the treatment of asymptomatic carotid stenosis? a Belgian multidisciplinary survey.

AIM: The aim of this study was to supplement the few data that exist regarding the potential effect of the referring medical specialty on the proposed treatment for asymptomatic carotid stenosis. METHODS: In a web survey, we presented Belgian cardiologists, neurologists and vascular surgeons with two fairly uncomplicated case vignettes on asymptomatic carotid stenosis differing only in the degree of stenosis (70-80% in case 1 and >80% in case 2). RESULTS: In both cases the suggested therapies were different per medical specialty (P<0.000002 and P<0.00002, respectively). Cardiologists were more conservative and vascular surgeons were more aggressive. Preferred therapies for both cases differed statistically significantly (odds ratio 8.63; 95% confidence interval 5.11-14.58). Suggesting a different therapy or not for case 1 and case 2 was also different per medical specialty (P<0.035). Cardiologists were most inclined to suggest a different therapy and vascular surgeons the least. Nobody switched to a more conservative treatment. Younger physicians suggested a more conservative approach (P<0.014). CONCLUSION: Different medical specialties prefer different treatments for asymptomatic carotid stenosis. Also, younger physicians seem more conservative. We elaborate on the different reasons that could explain these findings.

Preoperative mapping for haemodialysis access surgery with CO(2) venography of the upper limb.

OBJECTIVE: This study aims to evaluate the impact of CO(2) venography on the planning and outcome of native arteriovenous fistula (AVF) creation. METHODS: Records of patients who underwent CO(2) venography prior to access surgery between January 2000 and December 2008 were reviewed. CO(2) venography was performed selectively in chronic kidney disease (CKD) in stage IV-V patients without suitable veins on clinical examination. Findings at surgery were compared to CO(2) venography images. Patency of AVFs was analysed by the Kaplan-Meier method. Differences in outcome of maturation were compared using a chi(2) test. RESULTS: A total of 209 CO(2) venograms were obtained in 116 patients. In 89 patients (77%), 101 AVFs (21 forearm AVF (21%) and 80 elbow AVF (79%) were created. Surgical findings corresponded with CO(2) venography findings in 90% of patients. In 10 cases (10%), access was created at the elbow despite a patent forearm cephalic vein on CO(2) venography (n = 2) or access was attempted with a vein which was thought to be unsuitable on CO(2) venography (n = 8). Maturation rate of the latter was 50% (4/8) vs. 88% (80/91) for AVFs created with veins considered usable (P = 0.004). The overall maturation rate was 84% with 1-year primary, assisted primary and secondary patency rates of 63%, 70% and 71%, respectively. CONCLUSION: CO(2) venography is a useful tool for venous mapping prior to vascular access surgery, resulting in an overall maturation rate of 84% and good patency rates.

Intraluminal fibre-tip centring can improve endovenous laser ablation: a histological study.

OBJECTIVE: In this histological study, the lateral saphenous vein of the goat was treated using a laser fibre to which a tulip-shaped, self-expandable catheter had been fixed to achieve endovenous laser ablation (EVLA). The catheter centres the laser fibre in the vein preventing direct contact with the vein wall. This study aims to establish whether prevention of direct contact between the fibre tip and the vein wall prevents ulceration and perforation of the vein wall and perivenous tissue destruction. MATERIALS AND METHODS: Ten lateral saphenous veins were treated, using the tulip catheter, in goats under general anaesthesia. Ten more veins were treated with a normal bare fibre. We used a 980 nm diode laser to provide the energy. Postoperatively the veins were removed immediately, at 10 days and after 3 weeks for histological examination. Destruction of the vessel wall was measured and perivenous tissue destruction was quantified using a graded scale. RESULTS: Ulceration and perforation were prevented when using the tulip catheter. It also achieved more even vein wall necrosis. Tulip-catheter-treated veins show a transmural vein wall necrosis in, on average, 80% of the total circumference compared to 64% in bare-fibre treated veins. Less perivenous tissue destruction was seen with the new catheter (perivenous tissue destruction scale: tulip catheter: 1.7 vs. bare fibre: 3.8). Three weeks after treatment, we found regression of the perivenous tissue destruction as the healing process continued. CONCLUSIONS: EVLA using the tulip catheter avoids ulceration and perforation of the vein associated with treatment using a bare fibre. It also results in more even circumferential vein wall necrosis and less perivenous tissue destruction.

Treatment of mycotic aneurysms with involvement of the abdominal aorta: single-centre experience in 44 consecutive cases.

OBJECTIVE: To review our management of mycotic aneurysms involving the abdominal aorta over the past 2 decades to assess the safety and efficacy of in-situ and extra-anatomic repair combined with antibiotic treatment. MATERIALS AND METHODS: From March 1990 to August 2008, 44 patients with a mycotic aneurysm involving the abdominal aorta were treated at our University Hospital. For all patients, we recorded the aetiology, clinical findings and anatomic location of the aneurysm, as well as bacteriology results, surgical and antibiotic therapy and morbidity and mortality. RESULTS: Twenty-one (47.7%) of the mycotic aneurysms had already ruptured at the time of surgery. Free rupture was present in nine patients (20.5%). Contained rupture was observed in 12 patients (27.3%). Urgent surgery was performed in 18 cases (40.9%). Revascularisation was achieved by in-situ reconstruction in 37 patients (84.1%), while extra-anatomic reconstruction was performed in six patients (13.6%). One patient (2.3%) was treated with a combined in-situ and extra-anatomic reconstruction. In one case (2.3%), endovascular aneurysm repair (EVAR) was performed. In-hospital mortality was 22.7%, 50% in the extra-anatomic reconstruction group and 18.9% in the in-situ repair group. One-third (33.3%) of our patients, who presented with a ruptured mycotic aneurysm died in the peri-operative period. This mortality was 13% in the patient-group presenting with an intact aneurysm. Of the 34 surviving patients, 12 patients (27.3% of surviving patients died after discharge from our hospital. In half of these patients, an acute cardiac event was to blame. Three patients (8%) showed re-infection after in-situ reconstruction. CONCLUSION: Management of mycotic aortic aneurysms remains a challenging problem. The results of surgery depend on many factors. In our experience, in-situ repair remains a feasible and safe treatment option for patients who are in good general condition at the time of surgery.

Conversion during laparoscopic aortobifemoral bypass: a failure?

OBJECTIVES: To study the impact of conversion on postoperative recovery, morbidity and mortality in laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease (AIOD). DESIGN: Retrospective analysis of a prospectively maintained database. METHODS: Between November 2002 and December 2006, 139 patients were treated for severe AIOD with a laparoscopic aortobifemoral bypass at one community and one university hospital. Demographic data, operative data, postoperative recovery data, morbidity and mortality were recorded and analysed according to a conversion and a non-conversion group. RESULTS: Conversion was needed in 13.7% of the patients. Morbidity was 16.5%-14.2% in the non-conversion group and 31.8% in the conversion group. Systemic morbidity was significantly higher in the conversion group (31.6% vs.10%; p=0.002), but only one patient had incomplete recovery; local morbidity was comparable in both groups (10.5% vs. 5.8%; p=0.337). Mortality rate was 2.2%. CONCLUSION: Laparoscopic aortobifemoral bypass surgery is a safe procedure for the treatment of AIOD. The outcome of patients after conversion is not affected in the way that it could be an impediment to start a laparoscopic procedure. Conversion in time is a safe way to overcome the learning curve.