Therapeutic outcomes of embolotherapy of extremity bone intraosseous arteriovenous malformation with ethanol, coils, and n-butyl cyanoacrylate.

OBJECTIVE: We evaluated the therapeutic outcomes of embolotherapy for bone arteriovenous malformations (AVMs) affecting the extremities using ethanol, coils, and n-butyl cyanoacrylate (NBCA). METHODS: We reviewed the data from 36 patients (18 males, 18 females; mean age 25 years; age range, 1-64 years) with bone AVMs affecting their extremities who had undergone embolotherapy using ethanol, coils, and NBCA from December 1996 to July 2019. Of the 36 patients, 19 had had pure bone AVMs and 17 mixed bone and soft tissue (MBS) AVMs. Embolotherapy was performed using direct puncture or a transvenous or an intra-arterial approach (range, 1-18 procedures; mean, 5 procedures). During the 178 embolotherapy procedures, ethanol was used in all 36 patients, except for 1. Coils were used in 14 patients, and NBCA and a lipiodol mixture in 9 patients. The therapeutic outcomes were evaluated by the clinical symptom response and the degree of devascularization on follow-up angiography or computed tomography. The major and minor complications were also evaluated. RESULTS: The clinical success (cure or markedly improvement) rate of embolotherapy for pure bone AVMs was significantly better than that for the MBS AVMs (88% vs 18%; P < .001). The complete devascularization rate of the bone AVM component of the MBS AVMs was 71%; however, the cure rate of the MBS AVMs was 0% owing to the remaining soft tissue AVMs. Of the 36 patients, 12 experienced complications, including 11 minor (2 skin bullae formation and 10 transient peripheral nerve injury) and 1 major (longstanding nerve palsy). CONCLUSIONS: Embolotherapy for bone AVMs affecting the extremities using ethanol, coils, and an NBCA mixture is effective and safe for the resolution or improvement of symptoms, especially in those with pure bone AVMs.

Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea.

BACKGROUND: Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. METHODS: All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. RESULTS: Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192-224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301-29.477; P = 0.001) mortality in all patients. CONCLUSION: Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.

Comparative Analysis Using Propensity Score Matching Analysis: Primary Closure versus Patch Angioplasty During Carotid Endarterectomy.

BACKGROUND: Primary closure (PC) and patch angioplasty (PA) during carotid endarterectomy (CEA) have been disputed in many studies. Some studies announced that PC is associated with a higher restenosis rate. The aim of this study was to evaluate the outcomes of PC and PA using propensity score matching (PSM). METHODS: Between November 1994 and October 2016, 1,044 patients underwent primary CEA procedures at our institution and were retrospectively analyzed. The study endpoints included rates of ipsilateral stroke, any clinical stroke, cranial nerve palsy, hematoma, bleeding warranting repeat surgery within 30 postoperative days. We also investigated the restenosis rates, overall survival, stenosis-free survival, and stroke-free survival during follow-up (median follow-up 37.1 months). RESULTS: This study includes 435 cases of PC and 476 cases of PA. After PSM analysis, baseline characteristics (age, gender, hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status within 6 months) were balanced. Finally, 377 pairs of matched cases were analyzed. Statistical analysis showed no significant differences between the 2 groups in ipsilateral stroke (P = 0.45), clinical stroke (P = 0.75), cranial nerve palsy (P = 1), hematoma (P = 0.18), bleeding which required reoperation (P = 0.12) within 30 postoperative days, and restenosis rates during follow-up (P = 0.16). In addition, there were no differences between the 2 groups during follow-up in overall, stroke-free, and restenosis-free survival with P values of 0.136, 0.07, and 0.06, respectively. CONCLUSIONS: According to the analysis using PSM, there were no significant differences between PC and PA closure during CEA in perioperative and long-term outcomes.

The Effect of Left Renal Vein Division on Renal Function Following Open Abdominal Aortic Surgery Using Propensity Score Matching Analysis.

BACKGROUND: Open surgery of abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD) sometimes requires left renal vein division (LRVD) to gain adequate exposure of the abdominal aorta. The aim of this study is to evaluate the effect of LRVD on the postoperative renal function using propensity score matching (PSM). METHODS: From July 1996 to January 2018, we retrospectively reviewed 698 patients who underwent open aortic surgery, including 543 AAAs and 155 AIODs, at a single institution. 66 patients (9.6%, 47 AAAs, 19 AIODs) needed LRVD during the operation. A 1:3 ratio PSM was used to control the selective bias between the LRVD and non-LRVD groups. We investigated preoperative and postoperative renal function including serum creatinine (sCr) level and estimated glomerular filtration rate (eGFR, mL/min/1.73 m2). Major complications, long-term renal function, and 30-day mortality were also compared. RESULTS: The LRVD group had a significantly higher rate of renal artery reconstruction (15.2% vs. 3.3%, P < 0.001) and suprarenal clamping (54.6% vs. 9.5%, P < 0.001) and higher incidence of juxtarenal AIOD (24.2% vs. 5.4%, P < 0.001). With PSM, 63 patients in the LRVD group and 144 patients in the non-LRVD group were enrolled in this study. The baseline characteristics were well balanced in the groups after PSM. There were no significant differences in preoperative eGFR (72.4 ± 21.3 vs. 76.1 ± 25.0, P = 0.306) and postoperative eGFR on day 3 (69.5 ± 26.6 vs. 77.5 ± 28.5, P = 0.065), day 7 (73.3 ± 24.8 vs. 78.5 ± 27.4, P = 0.264), and in the long-term follow-up period (69.0 ± 22.2 vs. 68.9 ± 27.1, P = 0.986, 50.2 month ± 45.50) in the 2 groups. Only the sCr level (1.40 ± 0.59 vs. 1.21 ± 0.62, P = 0.045) and eGFR (59.5 ± 23.9 vs. 71.4 ± 26.0, P = 0.002) were significantly worse on postoperative day 1 in the LRVD than in the non-LRVD group. There were no significant differences in 30-day mortality (1.6% vs. 1.6%, P = 1.00). CONCLUSIONS: The patients in the LVRD group underwent initial drop in renal function; however, eGFR improved during the follow-up period. There was no difference in renal function and postoperative mortality between LRVD and non-LRVD groups. Therefore, LRVD is a safe and durable procedure during complex abdominal aortic surgery.

Subclassification and Treatment Results of Ethanol Embolotherapy of Type II Arteriovenous Malformations of the Extremity and Body.

PURPOSE: To evaluate the safety and efficacy of ethanol and coil embolization of type II arteriovenous malformation (AVM) according to a new subtype classification. MATERIALS AND METHODS: Eighty-four type II AVMs in the body or extremity of 79 patients who underwent AVM treatment from 1996 to 2017 were retrospectively subclassified according to the angiographic morphology of the draining vein as type IIa (arterioles shunt to focal segment of single draining vein), type IIb (arterioles shunt to venous sac with multiple draining veins), and type IIc (arterioles shunt along long segment of draining vein). Coil and ethanol embolization of the focal or long segment of the draining vein or the venous sac was performed with direct puncture or transvenous approach according to subtype. Treatment outcomes, number of treatment sessions, and complications were analyzed. RESULTS: AVM cure (ie, complete embolization) rates were 95%, 76%, and 65% in types IIa, IIb, and IIc AVMs, respectively. The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs (P = .015). Median numbers of treatment sessions were 1 in types IIa and IIb AVMs and 2.5 in type IIc AVMs, with a significant difference between type IIc and the other 2 types (P < .05). Minor complications occurred in 20% of patents and major complications occurred in 7%. CONCLUSIONS: The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs, which also required significantly more treatment sessions than the other 2 types.

Treatment Strategies for Cephalic Arch Stenosis in Patients with Brachiocephalic Arteriovenous Fistula.

BACKGROUND: Cephalic arch is one of the sites most susceptible to stenosis in brachiocephalic arteriovenous fistula (BCAVF). We performed a retrospective study to identify the incidence of cephalic arch stenosis (CAS) in BCAVF, to compare the patency of percutaneous transluminal balloon angioplasty (PTA) with that of cephalic vein transposition (CVT), and to establish the optimal treatment strategy for CAS. METHODS: Between January 2011 and June 2016, 462 patients underwent BCAVF creation. CAS was defined as >50% stenosis at the confluence of the cephalic and axillary veins on ultrasonography. Treatment was planned for clinically significant CAS, which was defined as >25% reduction in flow volume compared to previous examination, elevation of venous pressure, delayed puncture site hemostasis, and/or acute thrombotic occlusion. RESULTS: Seventy-seven (16.7%) patients had CAS and 42 of them (54.5%) were treated for clinically significant CAS. PTA was performed in 36 patients (85.7%), and CVT was done in 6 patients (14.3%) as the initial treatment. Nine patients underwent CVT after PTA, resulting in a total of 15 patients treated with CVT. Investigation of the patency of the 36 cases of PTA and 15 cases of CVT revealed that primary-assisted patency rates at 6 and 12 months were 68.2% and 57.3% for PTA and 100.0% and 87.5% for CVT, respectively (P = 0.038). Secondary patency rates at 6 and 12 months were 72.0% and 56.9% for PTA and 100% and 100% for CVT, respectively (P = 0.010). The median intervention rate was 2.5 interventions per access-year in the 36 cases treated with PTA and 1.5 interventions per access-year in the 15 cases treated with CVT. CONCLUSIONS: CAS is a common cause of BCAVF dysfunction, and careful surveillance is warranted. CVT should be considered for treatment of CAS to achieve better long-term patency with fewer reinterventions.

Natural history of spontaneous isolated celiac artery dissection after conservative treatment.

OBJECTIVE: Optimal treatment of spontaneous isolated celiac artery dissection (SICAD) is not well established because the natural history of this rare disease is poorly understood. We analyzed the natural history of patients who underwent conservative treatment. METHODS: The study included 28 patients with SICAD from December 2008 to January 2017. Our institutional policy of first-line treatment for SICAD patients was conservative, and invasive procedures were reserved for unstable complications such as severe persistent pain, significant organ malperfusion, rapid aneurysmal change, and rupture or concealed rupture. Demographics, clinical features, morphologic characteristics on computed tomography, treatment modalities, and follow-up results of these patients were retrospectively reviewed. RESULTS: Mean age was 52 years, and 89% of patients were male; 86% presented with pain, mostly abdominal, and 14% of cases were detected incidentally on abdominal imaging. None of these patients had unstable complications on admission, and all underwent initial conservative treatment. During the follow-up period (22 ± 20 months), aneurysmal change and propagation of thrombosis were noted in one patient and two patients, respectively, all of whom were managed conservatively without adverse clinical events. No difference in clinical and morphologic outcomes was noted between patients who were treated with antihypertensive therapy and those who were not. Patients with intramural hematoma on initial images showed dynamic vascular remodeling (partial to complete resorption) during the follow-up period compared with patients who had dominant intimal flap on initial images. CONCLUSIONS: The clinical course of patients with SICAD was benign. Even progressive vascular changes during follow-up did not require invasive treatment. Antihypertensive therapy might not modify the clinical course. The short-term results of conservative management are encouraging, but further evaluation with long-term follow-up in a large population is needed.

Case Report of a Large Common Hepatic Artery Aneurysm.

Hepatic artery aneurysm is rare, but appropriate treatment is mandatory. We report a 50-year-old woman with an asymptomatic large hepatic artery aneurysm. The aneurysm was found as a result of abdominal computed tomography (CT) performed as a part of the screening. An open surgery was performed due to the size of the aneurysm. Aneurysmectomy was achieved, and the proper hepatic artery was anastomosed with gastroduodenal artery for adequate blood flow to the liver. Adequate hepatic circulation was confirmed postoperatively by duplex ultrasonography and CT. The patient was discharged on the 9th postoperative day.

Treatment strategy based on the natural course for patients with spontaneous isolated superior mesenteric artery dissection.

OBJECTIVE: The optimal treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD) is still not known, and we sought to determine an optimal treatment strategy for patients with SISMAD based on its natural clinical course. METHODS: We retrospectively reviewed consecutive patients with SISMAD treated from 2001 through 2016. Diagnosis and angiographic type of SISMAD were determined with contrast-enhanced computed tomography (CT) scan, and the clinical features were obtained using a fixed form questionnaire. All patients were treated conservatively, except for five who unselectively underwent primary interventional treatment. For the follow-up examinations, clinical features and morphologic changes of superior mesenteric artery dissection were examined with CT angiography every 6 to 12 months. RESULTS: During the past 15 years, 116 patients with SISMAD (male, 92%; mean age, 54.7 ± 10.8 years; symptomatic, 76%) were encountered. Clinical features and morphologic changes on CT examinations were available in 100% and 88% of the patients, respectively, during the mean follow-up of 53 ± 39 months (range, 1-173 months). Of 83 symptomatic patients managed conservatively, 96% achieved pain resolution; 4% experienced prolonged pain, including one patient with bowel gangrene. After pain resolution, 20% of patients developed late recurrence of abdominal pain, which was relieved with conservative management, whereas two patients (12%) required surgery to treat bowel stricture. Follow-up examinations (n = 102) by CT angiography revealed no change in 34%, partial or complete remodeling in 63%, aneurysmal change in 2%, and dissection progression in 1% of the patients. Antithrombotic therapy offered no beneficial effects on either clinical or morphologic outcomes. CONCLUSIONS: With conservative treatment, the majority of patients with SISMAD showed clinical improvement and no morphologic changes during long-term follow-up. We thus recommend a conservative management strategy as the first-line treatment for patients with SISMAD, regardless of angiographic type.

Treatment strategy based on the natural course of the disease for patients with spontaneous isolated abdominal aortic dissection.

OBJECTIVE: This study aimed to determine the natural history of spontaneous isolated abdominal aortic dissection (SIAAD) and to establish an optimal management strategy for patients with SIAAD. METHODS: We searched the database of thoracoabdominal computed tomography (CT) performed at a single institution from January 2003 to July 2016 using the keywords "aortic dissection" and "dissection AND aorta." Once a diagnosis of SIAAD was made, we investigated the initial clinical and morphologic features and aorta-related events for all patients and morphologic changes of the aortic dissection (AD) during the follow-up period for the patients who underwent follow-up CT scans. We compared characteristics of the patients, frequencies of clinical events (aortic rupture, intervention, death), and morphologic changes (false lumen enlargement, progression of AD, remodeling of AD, and involvement of iliac or visceral artery) during the follow-up period according to the location of AD (infrarenal vs suprarenal), symptom status (symptomatic vs asymptomatic), and gender. RESULTS: There were 210 (10.7%) patients (median age, 69.4 years [interquartile range, 61.3-74.7]; male, 73.3%) who were diagnosed with SIAAD among 1958 patients with AD. SIAAD was most frequently located at the infrarenal aorta (86.2%), extended to the iliac (12.4%) or visceral artery (2.9%), and was symptomatic in 13.3% of patients. During the study period, aortic rupture developed in two patients (0.9%), aortic intervention was required in five (2.4%), and aorta-related deaths were identified in three (1.4%). Among 138 (65.7%) patients who underwent follow-up CT scans, 81.9% showed no morphologic change or remodeling during the follow-up period (median, 25 months; range, 1-158 months; interquartile range, 12.3-49.1 months). In the meantime, false lumen enlargement and longitudinal progression of AD developed in 8.7% and 6.5% of patients, respectively. However, newly developed visceral artery extension was not found in any of the patents. When characteristics of the patients and frequencies of clinical events or late morphologic changes of AD were compared on the basis of the location of AD, symptom status, and gender, female gender, presence of symptoms, and suprarenal SIAAD were more frequently associated with aorta-related mortality. False lumen enlargement was more frequent in the suprarenal AD group than in the infrarenal AD group. CONCLUSIONS: Based on our observation, the majority of symptomatic and asymptomatic SIAAD patients can be managed conservatively unless they present with aortic rupture, concomitant large aortic aneurysm, or underlying connective tissue disease. However, a more proactive management strategy may be required for female, symptomatic patients or those with suprarenal SIAAD.

Editor's Choice - Comparison of Early Outcomes and Restenosis Rate Between Carotid Endarterectomy and Carotid Artery Stenting Using Propensity Score Matching Analysis.

OBJECTIVE/BACKGROUND: Despite randomised evidence, the debate continues about the preferred treatment strategy for carotid stenosis in routine clinical practice. The aim of this study was to compare early outcomes and restenosis rates after carotid endarterectomy (CEA) and carotid stenting (CAS) in unselected patients using propensity score matching (PSM). METHODS: The 30 day incidence of major adverse clinical events (MACE; defined as stroke, transient ischaemic attack, myocardial infarction, or death) and procedure related complications, as well as restenosis rates during follow-up were compared between unselected patients undergoing CEA or CAS between January 2002 and December 2015 at a single institution. PSM was used to balance the following factors between the CEA and CAS cohorts: age, sex, hypertension, diabetes, dyslipidaemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, valvular heart disease, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status. Statistical comparisons of outcomes were based on logistic regression analysis and log rank test. RESULTS: Of 1184 patients (654 CEA and 530 CAS), 452 PSM pairs of CEA and CAS patients were created. The CAS group showed a relatively higher 30 day incidence of MACE (7.5% vs. 2.4%; odds ratio [OR] 3.261, 95% confidence interval [CI] 1.634-6.509; p = .001) but a lower incidence of procedure related complications (1.5% vs. 5.3%; OR 0.199, 95% CI 0.075-0.528; p = .001). During a mean follow-up of 49.1 months (range 1-180 months), restenosis rates were higher after CAS than after CEA (1.5% vs. 1.0% at 12 months and 5.4% vs. 1.2% at 24 months, respectively; p = .008). CONCLUSION: This PSM based observation reconfirmed previous trial results in both asymptomatic and symptomatic patients with carotid artery stenosis in routine clinical practice: CEA showed lower 30 day MACE and mid-term restenosis rates than CAS.

Venous Reconstruction in Extremity Soft Tissue Sarcoma Is Not Essential.

OBJECTIVE: Limb salvage is an important concern following complete oncologic resection for extremity soft tissue sarcoma (STS). Vascular reconstruction is essential for limb salvage. The purpose of this study was to evaluate the outcomes of vascular reconstruction in patients with extremity STS. METHODS: This is a retrospective, multi-center, case series of consecutive patients who underwent vascular reconstruction during extremity STS resection at 2 major centers in Korea. Demographics, reconstruction methods, type of conduit, surgical complications, graft patency, limb salvage rate, and patient survival were reviewed. RESULTS: From March 2005 to December 2020, 43 patients underwent vascular reconstructions during STS resection. Among the patients, 22 (51.2%) received arterial only, and 21 (48.8%) received simultaneous arterial and venous reconstructions. For the types of conduits, autologous saphenous veins (56.2%), artificial grafts (26.3%), and cryopreserved allografts (15.8%) were used. During a median follow-up of 23.8 months (interquartile range; 7.7-54.5), the overall primary patency of the reconstructed vessels was significantly higher in arteries than in veins (82.5% vs 56.3% at 12 months, P < .001). According to the type of conduit, the primary patency rate of autogenous vein seemed higher in venous reconstruction, however, there was no statistical significance in both arterial and venous reconstruction. There was no significant difference in primary arterial patency rate (P = .132) or incidence of surgical complications including postoperative edema or wound problem whether or not simultaneous venous reconstruction was performed with arterial reconstruction. The overall limb salvage rate and patient survival were 97.4%, 95.1%, and 89.4% and 91.9%, 81.7%, and 65.4% at 12, 24, and 36 months, respectively. CONCLUSIONS: Patency rates were poorer in venous reconstruction than in arterial reconstruction. In terms of arterial patency and postoperative complication, the role of simultaneous arterial and venous reconstruction seems not essential, however, it needs to be evaluated in future studies.

Severe dysplasminogenemia due to homozygous PLG Ala620Thr variant in a Korean woman without a history of venous thromboembolism: A case report and literature review.

RATIONALE: Plasminogen plays an important role in fibrinolysis and is encoded by the PLG gene. The missense variant PLG Ala620Thr is the major cause of dysplasminogenemia in East Asian countries, including Korea. Although dysplasminogenemia was first reported in a Japanese patient with recurrent venous thromboembolism (VTE), subsequent studies have not demonstrated any clear association between the PLG Ala620Thr variant and the risk of VTE. To the best of our knowledge, this is the first report of a homozygous PLG Ala620Thr variant case from Korea. PATIENT CONCERNS: Here, we report a Korean family with PLG Ala620Thr mutation. The proband was a 34-year-old man who presented with multiple thrombotic arterial embolism and cardiac myxoma. INTERVENTIONS: Laboratory workup, including coagulation profile and PLG gene sequencing, was carried out for the affected family. DIAGNOSIS AND OUTCOME: The proband carried a heterozygous PLG Ala620Thr variant with decreased plasminogen activity of 65%. His 53-year-old mother, who had no reported history of VTE, was homozygous for the PLG Ala620Thr variant with decreased plasminogen activity of just 25%. Decreased plasminogen activity indicates dysplasminogenemia. LESSONS: We believe that this clinically silent homozygous case supports the previous findings that isolated PLG Ala620Thr variant does not confer a significant risk of VTE.

Factors associated with long-term graft patency after lower extremity arterial bypasses.

PURPOSE: This study was conducted to determine factors associated with long-term graft patency after lower extremity arterial bypass (LEAB). METHODS: Database of LEABs for patients with chronic arterial occlusive disease (CAOD) at a single institution was retrospectively reviewed. To determine the factors we compared demographic, clinical, and procedural variables between 2 patient groups; group I (graft patency < 2 years) and group II (graft patency ≥ 5 years after LEAB) using univariable and multivariable analyses. RESULTS: Among 957 LEABs, 259 limbs (group I, 125 limbs and group II, 134 limbs) in 213 patients were included for the analysis. On a univariable analysis, younger age (69 years vs. 66 years, P = 0.024), hypertension (60.8% vs. 74.6%, P = 0.017), claudication (51.2% vs. 70.9%, P = 0.001), absence of prior intervention (50.4% vs. 73.9%, P < 0.001), common femoral artery based bypass (57.6% vs. 70.1%, P = 0.035), above-the knee bypass (36.8% vs. 64.2%, P < 0.001), postoperative graft salvage procedure (3.2% vs. 14.8%, P = 0.001), and statin use (75.2% vs. 88.8, P = 0.004) were associated with long-term patency. On a multivariate analysis hypertension (odds ratio [OR], 1.91; P = 0.038), claudication (OR, 2.08; P = 0.032), no prior intervention (OR, 2.48; P = 0.001), vein graft (OR, 4.36; P = 0.001), above-the knee bypass (OR, 4.68; P < 0.001), and graft salvage procedures (OR, 7.70; P < 0.001) were identified as independent factors. CONCLUSION: These factors can be considered in decision making before treatment of patients with CAOD.

Mortality after Use of Paclitaxel-Coated Balloons Correlates with Total Cumulative Dosage of Paclitaxel in Real-World Analysis.

This study used independent, real-world, patient-level data to examine whether the dosage or frequency of paclitaxel exposure correlated with mortality during follow up. We conducted a retrospective analysis of patients treated with a drug-coated balloon (DCB) for an atherosclerotic femoropopliteal lesion from February 2013 to December 2018, excluding patients with non-atherosclerotic lesions or restenosis after DCB treatment in another hospital. We investigated the causes of death, comorbidities (including cancer status), and the initial and total cumulative dosages and frequency of paclitaxel use. To determine whether the dosage or frequency of paclitaxel exposure affected mortality during follow up, we analyzed the risk factors for all-cause death by conducting a time-dependent Cox regression analysis that considered demographics, comorbidities, lesion and procedural characteristics, and paclitaxel exposure data (dosage and frequency). Our analysis examined 225 patients (mean age 71 ± 9 years, range 38-93 years, male 81%). During a mean follow-up duration of 35 months (range 1-89 months), 56 patients (24.9%) died from cardiac disorders (16%, including acute myocardial infarction, heart failure, or sudden cardiac arrest), malignancy (14.3%), respiratory failure with pneumonia (12.5%), septic shock (12.5%), or another cause. Univariable and multivariable Cox regression analyses identified age (hazard ratio, HR, 1.057; 95% confidence interval, CI, 1019-1096; p = 0.0032), critical limb ischemia (CLI) (HR, 4135; 95% CI, 2171-7876; p < 0.0001), and the total dosage of paclitaxel (mg) (HR, 1.040; 95% CI, 1006-1074; p = 0.0210) as predictors of mortality during follow up. The subgroup analysis found that the total dosage of paclitaxel (mg) was also a predictor of mortality during follow up in the CLI group (HR, 1.046; 95% CI, 1007-1087, p = 0.0198). The estimated cut-off value of total cumulative paclitaxel dosage for predicting mortality was 12 mg as evaluated by minimum p value approach. This patient-level analysis identified the total cumulative dosage of paclitaxel as a predictor of mortality after the use of paclitaxel-coated balloons. Our results provide limited information about the potential dose-response relationship underlying paclitaxel-associated mortality concerns.

Differential Diagnosis and Treatment Outcomes of Tumors at the Carotid Bifurcation.

PURPOSE: Primary tumor at the carotid bifurcation is uncommon, which includes paraganglioma, schwannoma, and lymphoma. Due to their rarity, characteristics of these tumors and problems related to their surgical treatment have not been well known. We tried to elucidate different clinical characteristics and surgical complications of these tumors. MATERIALS AND METHODS: We retrospectively reviewed 21 patients with carotid bifurcation tumor from the Vascular Surgery division of a Korean tertiary institution from 1995 to 2018. We investigated patients' demographics and clinical features, image characteristics, treatment details, and surgical outcomes. RESULTS: During the period from January 1995 to January 2018, we experienced surgical resections of 21 carotid bifurcation tumors which included 16 (76.2%) paragangliomas and 5 (23.8%) schwannomas. The most common clinical feature was a non-tender cervical mass. According to Shamblin classification, paragangliomas were classified into class II in 68.8% and class III in 25.0%. On the preoperative computed tomography images, all the paragangliomas showed characteristic splaying of the carotid bifurcation and hypervascularity of the tumors. On the contrary, all the schwannomas showed hypovascularity and splaying sign in 60%. Surgical complications related to cervical nerve injury developed in 50% and 60% of patients with Shamblin class III paraganglioma and schwannoma, respectively. During the mean follow-up period of 25 months (range, 1 to 163 months), distant metastases developed in 2 (12.5%) of paraganglioma patients. CONCLUSION: Neurologic complications were more common after surgical resection of Shamblin class III paraganglioma and schwannoma. For patients with paraganglioma, postoperative periodic follow-up examination is advised to detect distant metastasis.

Strategy to avoid open surgical conversion after endovascular aortic aneurysm repair for patients with infrarenal abdominal aortic aneurysm.

PURPOSE: Open surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR)failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR. METHODS: We retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs. RESULTS: Two main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period. OSC was performed at a median of 31.8 months (interquartile range, 9.4-69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications. CONCLUSION: OSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.

Surgical Strategy to Reduce the Recurrence of Adventitial Cystic Disease after Treatment.

PURPOSE: Adventitial cystic disease (ACD) is a rare condition that causes intermittent claudication and non-atherosclerotic disease without cardiovascular risk factors. The etiology and optimal treatment of ACD remain controversial. The purpose of this study was to analyze surgical treatment results for ACD and to elucidate optimal treatment options. MATERIALS AND METHODS: We retrospectively reviewed 30 patients with ACD who underwent surgery from 2006 to 2018. Twenty-two patients had arterial ACD, six had venous ACD, and two had combined venous and arterial ACD. We reviewed demographic and clinical characteristics, treatment details, and procedure outcomes. RESULTS: Recurrence occurred in 6 cases either after cyst excision alone (4/17) or patch angioplasty (2/2). There was no recurrence after vessel excision with interposition grafting (0/7). Therefore, vessel excision was a statistically significant factor in recurrence prevention (P=0.026). Among the six recurrences, joint connections of the cystic lesions were found in four of the six (66.7%). CONCLUSION: As a curative surgery for ACD, vessel excision with interposition grafting is a better strategy to prevent recurrence than simple cyst excision alone.

A Case Report of the Intravascular Fasciitis of a Neck Vein Mimicking Intravascular Tumorous Conditions.

Intravascular fasciitis is a rare variant of nodular fasciitis, which can be easily misdiagnosed as a tumorous condition. We had a patient with an intravenous mass of a neck vein, and surgical excision was successful. Although all preoperative imaging studies and intraoperative pathologic reports suggested certain tumorous conditions as differential diagnosis results, the final diagnosis confirmed that it was an intravascular fasciitis based on its fibromixoid tissues with the proliferation of spindle cells and positive immunohistochemical staining for smooth muscle actin. Unless a physician has an insight of the disease or a suspicion to initiate running differential markers, it may be confused with other intravascular lesions and cause unnecessary radical surgery. Here we report our experience with a patient having this rare vascular disease.