Percutaneous intervention in peripheral artery disease improves calf muscle phosphocreatine recovery kinetics: a pilot study.

We hypothesized that percutaneous intervention in the affected lower extremity artery would improve calf muscle perfusion and cellular metabolism in patients with claudication and peripheral artery disease (PAD) as measured by magnetic resonance imaging (MRI) and spectroscopy (MRS). Ten patients with symptomatic PAD (mean ± SD: age 57 ± 9 years; ankle-brachial index (ABI) 0.62 ± 0.17; seven males) were studied 2 months before and 10 months after lower extremity percutaneous intervention. Calf muscle phosphocreatine recovery time constant (PCr) in the revascularized leg was measured by (31)P MRS immediately after symptom-limited exercise on a 1.5-T scanner. Calf muscle perfusion was measured using first-pass gadolinium-enhanced MRI at peak exercise. A 6-minute walk and treadmill test were performed. The PCr recovery time constant improved significantly following intervention (91 ± 33 s to 52 ± 34 s, p < 0.003). Rest ABI also improved (0.62 ± 0.17 to 0.93 ± 0.25, p < 0.003). There was no difference in MRI-measured tissue perfusion or exercise parameters, although the study was underpowered for these endpoints. In conclusion, in this pilot study, successful large vessel percutaneous intervention in patients with symptomatic claudication, results in improved ABI and calf muscle phosphocreatine recovery kinetics.

The incidence of pulmonary neoplasms discovered by serial computed tomography scanning after endovascular abdominal aortic aneurysm repair.

OBJECTIVES: Serial computed tomography (CT) scanning is routinely used to follow up endovascular exclusion of abdominal aortic aneurysms (AAAs). Nonvascular diseases can be identified, and these exams include images of the lung bases, which can provide information that leads to the diagnosis of pulmonary neoplasms. This study was conducted to determine the rate and type of pulmonary-based oncologic diseases identified by serial CT scanning of patients with endovascular repair of AAAs. METHODS: A retrospective review of 138 consecutive patients receiving endovascular AAA exclusion during an 8-year period was performed. Length of follow-up and number of CT scans performed was recorded. CT characteristics of the lesion (size, character, and suspicion of malignancy), type of biopsy procedure performed, and final pathologic diagnosis were collected. Oncologic treatments and survival length were also evaluated. RESULTS: Pulmonary lesions were found in 25 patients (18%), of whom 5 (4%) died during follow-up, and 13 (9%) had stable, subcentimeter lesions and continue to have surveillance from vascular specialists only. Seven patients (5%) with pulmonary lesions were referred for evaluation by thoracic surgeons. Six patients (4%) underwent biopsy of the lesion and were diagnosed with cancer. One patient refused a biopsy and is being monitored with serial CT scans. Four lung cancers (1 small cell and 3 non-small cell), one primary pulmonary carcinoid tumor, and one B-cell lymphoma were discovered. No changes were noted in the lesions in the patient receiving CT surveillance. More than half of the cancers were diagnosed in stage I, with a mean lesion diameter of 11 mm at biopsy. Of 25 patients with pulmonary nodules, 24 were men. The patients diagnosed with cancer are all still alive, with a mean survival length of 2.5 years (range, 0.5-6 years) after oncologic treatment. CONCLUSIONS: Serial CT scans may reveal a high rate of pulmonary malignancies in a population with AAAs. Attention to the incidental finding of pulmonary nodules on CT scans and arrangement of appropriate follow-up by the vascular surgeon is important for patients undergoing surveillance after endovascular AAA repair. These results indicate that aggressive management of these lesions (early thoracic surgery consultation and biopsy) is appropriate in this high-risk population and may offer early diagnosis and improved long-term survival.

The plasma microparticle proteome.

All cell types shed ectosomes and exosomes, collectively known as microparticles (MP; 0.1 to 1.5 µm in diameter), when activated or stressed; normal human plasma contains ~2 µg MP protein/mL. The cellular composition of plasma MP is altered in many diseases, including acute coronary syndrome, diabetes mellitus, sepsis, and sickle cell disease. We measured the plasma MP protein composition of 42 patients (median age 69.5 years, most with cardiovascular disease) by label-free liquid chromatography coupled to tandem mass spectrometry. Among 458 proteins detected with high confidence (identified by at least two unique peptides with SEQUEST XCor (Thermo Electron Corp., San Jose, CA) ≥ 2.0, 2.2, and 3.3 for charge states +1, +2, and +3, respectively), 130 were present in most patients, representing a "core" set of plasma MP proteins. This core is enriched in cytoskeletal, integrin complex, and hemostasis proteins, and spectral counts of several proteins correlate with patient age and gender. We conclude that the MP proteome may be a useful and reliable source of biologically relevant disease biomarkers.

Atrial fibrillation is associated with increased risk of perioperative stroke and death from carotid endarterectomy.

BACKGROUND: Carotid endarterectomy is performed in high volume in the United States. Identifying patients with a higher risk of stroke and death after carotid endarterectomy can lead to modifications in care that would significantly reduce the occurrence of these events. This study evaluates whether atrial fibrillation is significantly associated with an increased risk of death or stroke for patients undergoing carotid endarterectomy. METHODS: This retrospective cohort study uses multivariable logistic regression analysis to assess the relationship between atrial fibrillation and death and/or stroke after carotid endarterectomy. The study population is drawn from the National Inpatient Sample, 2005. All patients with a primary carotid endarterectomy and diagnosis of stenosis of precerebral arteries were included, except patients with concomitant open heart procedures. The main outcomes examined were in-hospital death and stroke, adjusted for age, gender, symptomatic status, and for comorbid disease. RESULTS: Carotid endarterectomy was performed for 20,022 patients. Strokes occurred in 189 patients (0.94%), and death occurred in 59 (0.29%). Patients with atrial fibrillation had significantly higher adjusted odds of stroke or death (odds ratio = 2.45; P < .0001). CONCLUSION: Patients with atrial fibrillation have a substantially higher risk of stroke and death after carotid endarterectomy.

Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation.

PURPOSE: To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation. MATERIALS AND METHODS: A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented. RESULTS: Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023). CONCLUSIONS: The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents.

Unusual anomaly complicating abdominal aortic aneurysm repair: anterior inferior vena cava.

This case illustrates an unusual anomaly of the great veins. To our knowledge, these are the first published photographs of the vena cava traversing anterior to the distal aorta. This anatomic variant caused minor technical problems during open abdominal aortic aneurysm repair.

Current issues in the treatment of women with abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA) accounts for approximately 45,000 deaths per year in the United States. Despite a striking male predominance of AAA (4:1 male to female), mortality from this disease is almost as high in women (20th leading killer of women and 15th leading killer of men in this country). OBJECTIVE: The purpose of this review is to highlight the differences in diagnosis, treatment, and treatment outcomes for women with AAA to determine avenues of potential improvement in their care. METHODS: Published articles relevant to this review were determined by the experience of the author, by PubMed and MEDLINE searches, and by reviewing the references cited in the reports identified by the first 2 methods. The database searches were performed using the following terms: abdominal aorta, aneurysm, gender, endovascular, and outcomes. Reports were limited to the English language and publication since 1995. RESULTS: Compared with men, women are older when their AAA is diagnosed and treated. Women have higher mortality than do men while undergoing elective open and endovascular repairs, and emergency surgery for ruptured AAAs. Owing to the anatomic complexity of their arterial anatomy, women are less frequently candidates for endovascular repair. Women receive treatment for rupture of AAA less frequently than do men. On Medicare induction, both men and women are eligible for a one-time screening for AAA; however, women qualify for this exam only if they have a family history of AAA. CONCLUSIONS: Opportunities to advance the care of women with AAA include improving screening techniques to find AAA prior to rupture and when women are younger and more likely to be candidates for repair. Current clinical practice should focus on decreasing mortality for open surgical repair and developing better endovascular devices so that anatomic obstacles can be overcome and more women can be candidates for this technology. In addition, furthering the understanding of gender differences in the pathophysiology of AAA disease may provide insights into treatments that could prevent the formation of aneurysms.

CTA and MRA in mesenteric ischemia: part 2, Normal findings and complications after surgical and endovascular treatment.

OBJECTIVE: A number of surgical and endovascular options exist for the treatment of acute and chronic mesenteric ischemia. Both surgical and endovascular treatments necessitate close clinical and imaging follow-up because the consequences of acute occlusions can be catastrophic. MDCT angiography (CTA) and contrast-enhanced MR angiography (MRA) are the preferred imaging techniques in this setting. CONCLUSION: We review the appearance of the normal and complicated surgical and endovascular treatment on CTA and MRA.

Evaluation of the effect of endovascular options on infrarenal abdominal aortic aneurysm repair.

Endovascular devices designed to exclude flow to infrarenal abdominal aortic aneurysms (AAA) were approved by the Food and Drug Administration in the United States in 1999. This action allowed widespread use of this technology for AAA exclusion. The purpose of this report is to examine trends for use of these modalities, rates of rupture of AAA, and to compare results of open AAA repair with endovascular repair. Results were collected for all hospitals, except for Veterans Administration hospitals, by a state-wide repository. Data for the years 1996 through 1998 and 2001 through 2002 were evaluated, and data from 1999 through 2000 were excluded because no separate codes were available to distinguish between open and endovascular repair. The information gathered is based on the All Patient Refined Diagnostic Related Group (APRDRG; 3M, St. Paul, MN). An average of 718 open, elective AAA was performed between 1996 and 1998. This dropped to 503 open repairs from 2001 to 2002 (P < 0.005). During that same interval, 308 endovascular elective AAA repairs were performed, therefore the total rate of elective repair increased by 100. The average rate of ruptured AAA repairs from 1996 to 1998 was 121 per year, and this dropped to 89 from 2001 to 2002 (P < 0.005). The mortality of open AAA repair during the 1996 to 1998 and 2001 to 2002 intervals was unchanged (4.7%). Mortality from endovascular AAA repair between 2001 and 2002 was 1.9 per cent (P = 0.003). Major morbidity was 14.5 per cent for open, elective AAA repair and 6.3 per cent for endovascular elective repair from 2001 to 2002 (P < 0.001). These data suggest that the advent of endovascular AAA repair has contributed to a reduction in the rate of ruptured AAA repairs, an increase in total procedures performed, and a significant decrease in perioperative deaths and major complications when compared with open AAA repair.

Carotid endarterectomy: update on the gold standard treatment for carotid stenosis.

Many prospective, randomized clinical trials evaluating the safety and efficacy of carotid endarterectomy (CEA) versus medical management in the prevention of ischemic stroke were performed in the 1990s. Clinical trials are underway that will compare CEA outcomes to carotid stenting; however, relatively few studies have examined the outcomes of modern CEA. The purpose of this report is to examine current outcomes of CEA and evaluate hospital costs and length of stay. Statewide results were collected for all hospitals, except Veterans Administration hospitals, by Virginia Health Information (VHI). Data for the years 1997-2001 were evaluated, and data were based on the All Patient Refined Diagnostic Related Group (APR-DRG; 3M Company). A total of 14,095 CEAs were performed in a 5-year period. The mortality of patients undergoing CEA was 0.5 per cent. The stroke rate was 1 per cent overall and decreased each year of the study. Mean and median lengths of hospital stay were 3 and 2 days, respectively. Length of stay decreased over the course of this study. Mean and median hospital costs were 14,331 dollars and 11,268 dollars. Higher rates of mortality and stroke and higher costs were observed at low-volume hospitals. The need for CEA is substantial. CEA is safe and inexpensive. The data presented here demonstrates continued refinement in CEA, leading to a very low rate of perioperative adverse events, declining lengths of stay, and low hospital costs.

Remediation of low ABSITE scores.

PURPOSE: In 2000, a program was initiated to improve American Board of Surgery In-Training Exam (ABSITE) scores below the 40th percentile (PGY-1 and -2) and the 30th percentile (PGY-3 and -5) for categorical residents. The goal of this program is to maintain scores above this standard. METHODS: One faculty member was designated to meet with each resident with ABSITE scores below the standard described above. In April, individual study plans were designed with each resident, which emphasized practice questions and strategic planning for study, and the ABSITE test structure and results were reviewed. Two subsequent meetings were held between November and December to monitor progress. Emphasis was placed on minimizing the stigma of poor scores and on maximizing the efficiency of study time. If the resident scored above-standard that year, further support was not required. RESULTS: From 2000 to 2004, 12 (9.5%) ABSITE scores were below-standard, which resulted in 8 (20.5%) residents receiving program support 9 times. All but 1 program encounter resulted in above-standard scores the following year (improvement range, 16 to 65 percentile points; average, 34 points). Two residents had recurrent below-standard scores in subsequent years despite above-standard scores immediately after the program. One resident did not participate in the program, despite it being designated as mandatory. During the same interval, the ABSITE scores of residents not involved in the program decreased by an average of 3.7 percentile points per examination (improved scores 31 times; 39.2%, range 1 to 46, average 13.5, worse scores 45 times; 57%, range 1 to 65, average 15.2, and no change 3 times, 3.8%). CONCLUSIONS: An individualized program that minimizes the stigma of poor test results, the time commitment required by the residents, and maximizes the benefits of a question-based study system and the knowledge of approach to the ABSITE resulted in significant improvements in scores the next year. However, maintenance of these results needs continued evaluation because 3 residents had recurrent poor scores in subsequent years.

Subfascial endoscopic perforating vein surgery (SEPS) for the treatment of venous ulcers.

Lower extremity ulcerations that result from venous hypertension are a significant cause of disability in Western nations. Venous ulcers, highly related to lower extremity venous valvular incompetence and post-thrombotic syndrome, demonstrate a protracted course of healing with a high recurrence rate when managed conservatively. Effective treatment includes correcting the elevated lower extremity venous pressure using non-invasive (compression therapy) or invasive modalities (removal or correction of incompetent venous segments, most commonly the greater saphenous vein). Minimally invasive subfascial endoscopic perforating vein surgery, performed on an outpatient basis, allows ligation of incompetent Cockett perforating veins. Venous ulcer healing rates of 88% and infrequent wound complications have been reported using this technique. Using 5-mm cameras and trocars that are available for other endoscopic surgeries could further improve this technique; creating ports smaller than the traditional 15-mm incisions would subsequently reduce tissue disruption. In addition, the etiology of recurrent ulceration and the failure of the primary ulcer to heal are not completely understood. If these poor outcomes can be further defined, even higher rates of wound healing may be attained using this procedure. Significant efforts have been devoted to elucidating the exact mechanism of skin breakdown from venous hypertension but the pathophysiology of this process is still not understood.

Safety and efficacy of the supraclavicular approach to thoracic outlet decompression.

BACKGROUND: Thoracic outlet syndrome (TOS) is a clinical diagnosis encountered by both thoracic and vascular surgeons. The goal of surgical therapy involves relieving compression of the neurovascular structures at the superior thoracic aperture. The traditional approach to thoracic outlet decompression has been transaxillary; however more centers are moving toward a more tailored approach through a supraclavicular incision. METHODS: The medical records of 67 patients who underwent surgical decompression between 1993 and 2001 for TOS were retrospectively reviewed. Patient demographics and early outcome were assessed through clinic follow-up. RESULTS: Seventy-two thoracic outlet decompressions were performed on 67 patients with the diagnosis of TOS. Five patients underwent bilateral thoracic outlet decompression. All operations in this time period were safely accomplished through a supraclavicular approach. The syndromes associated with thoracic outlet compression were neurogenic (n = 59), venous (n = 10), and arterial (n = 3). Forty-six of 72 (63.9%) operations resulted in complete resolution of symptoms, 17 cases (23.6%) had partial resolution, and 9 patients (12.5%) had no resolution. There were no deaths and morbidity was minimal with 6 complications (8.3%). CONCLUSIONS: The supraclavicular approach is a safe and effective technique in managing all forms of thoracic outlet compression.

Subintimal recanalization is safe and effective in treating chronic critical limb ischemia in selected patients.

Subintimal recanalization is a percutaneous technique that allows revascularization in patients with limb-threatening ischemia. It was first described by Bolia (Cardiovasc Intervent Radiol 13;357-63:1990) but has not gained widespread use in the United States. Twenty-five patients with 32 threatened limbs were referred from a single surgeon's practice over a 23-month period. All patients were either high-risk surgical patients, due to severe medical comorbidities, or not surgical candidates due to poor target vessels, lack of appropriate conduit, or failed previous surgical revascularizations. The average age of patients was 69. There were 15 men and 10 women treated. Subintimal recanalization was immediately successful in 30 limbs. One peri-procedural death occurred, although this patient underwent a surgical bypass graft procedure in the same hospitalization. Three significant complications occurred (myocardial infarction, ventricular arrhythmia, and gastrointestinal hemorrhage). Primary patency is 83 per cent. Secondary patency is 90 per cent. Limb salvage rate is 88 per cent. Mean follow-up period is 10 months. Eight patients died in the follow-up period due to unrelated causes.

An unusual case of Bouveret's syndrome.

A 69-year-old man presented to the emergency department with a 12-hour history of severe abdominal pain. His medical history was significant for a small-bowel obstruction that resolved with conservative therapy 4 months prior to admission. In the distant past, a Billroth II gastric resection was performed for ulcer disease. He was hypothermic, and laboratory studies showed elevated serum liver and pancreatic enzymes. A CT scan of the abdomen demonstrated fat stranding and a small amount of free air in the area of the pancreas. Gram-negative rods subsequently grew from blood cultures. A presumptive diagnosis of necrotising pancreatitis was made, and supportive care was instituted. Follow-up CT scan performed several days later demonstrated a large filling defect in the stomach. Endoscopy showed this defect to be a giant gallstone, and the diagnosis of Bouveret's syndrome was made. The patient underwent laparotomy. A duodenal perforation in the posterior aspect of the fourth portion was identified. The perforation had been caused by chronic impaction of the giant stone. The stone was removed through the perforation, and the perforation was closed in multiple layers. Drainage of the retroperitoneum was effected through large catheters placed through the flank. The presentation, diagnostic evaluation, treatment, and complications of this condition are discussed.

Vascular surgery career resource.

Vascular surgery has undergone a minimally invasive revolution in the past 15 years. The subspecialty emerged with many changes to its training paradigms that have made this field more attractive to both medical student and general surgery resident candidates. Commitment to diagnosis and treatment of arterial, venous, and lymphatic systems disorders remains the cornerstone of this profession, but an entirely new generation of endovascular treatments has been added to the staple of open surgical procedures used to treat these diseases. A wide variety of practice options are available, ranging from high-stress, technologically demanding complex arterial repairs to low-risk, outpatient, venous insufficiency treatment and all combinations in-between. Many online resources are available to allow an interested candidate to stay current with all the exciting changes in the field. This information is maintained by strong national organizations of vascular surgeons.

Metachronous bilateral posterior tibial artery aneurysms in Ehlers-Danlos syndrome type IV.

Ehlers-Danlos syndrome type IV is a life-threatening genetic connective tissue disorder. We report a 24-year-old woman with EDS-IV who presented with metachronous bilateral aneurysms/pseudoaneurysms of the posterior tibial arteries 15 months apart. Both were treated successfully with transarterial coil embolization from a distal posterior tibial approach.

Low-density lipoprotein lowering does not improve calf muscle perfusion, energetics, or exercise performance in peripheral arterial disease.

OBJECTIVES: We hypothesized that low-density lipoprotein (LDL) reduction regardless of mechanism would improve calf muscle perfusion, energetics, or walking performance in peripheral arterial disease (PAD) as measured by magnetic resonance imaging and magnetic resonance spectroscopy. BACKGROUND: Statins improve cardiovascular outcome in PAD, and some studies suggest improved walking performance. METHODS: Sixty-eight patients with mild to moderate symptomatic PAD (age 65 ± 11 years; ankle-brachial index [ABI] 0.69 ± 0.14) were studied at baseline and annually for 2 years after beginning simvastatin 40 mg (n = 20) or simvastatin 40 mg/ezetimibe 10 mg (n = 18) if statin naïve, or ezetimibe 10 mg (n = 30) if taking a statin. Phosphocreatine recovery time was measured by (31)P magnetic resonance spectroscopy immediately after symptom-limited calf exercise on a 1.5-T scanner. Calf perfusion was measured using first-pass contrast-enhanced magnetic resonance imaging with 0.1 mM/kg gadolinium at peak exercise. Gadolinium-enhanced magnetic resonance angiography was graded. A 6-min walk and a standardized graded Skinner-Gardner exercise treadmill test with peak Vo(2) were performed. A repeated-measures model compared changes over time. RESULTS: LDL reduction from baseline to year 2 was greater in the simvastatin 40 mg/ezetimibe 10 mg group (116 ± 42 mg/dl to 56 ± 21 mg/dl) than in the simvastatin 40 mg group (129 ± 40 mg/dl to 90 ± 30 mg/dl, p < 0.01). LDL also decreased in the ezetimibe 10 mg group (102 ± 28 mg/dl to 79 ± 27 mg/dl, p < 0.01). Despite this, there was no difference in perfusion, metabolism, or exercise parameters between groups or over time. Resting ABI did improve over time in the ezetimibe 10 mg group and the entire study group of patients. CONCLUSIONS: Despite effective LDL reduction in PAD, neither tissue perfusion, metabolism, nor exercise parameters improved, although rest ABI did. Thus, LDL lowering does not improve calf muscle physiology or functional capacity in PAD. (Comprehensive Magnetic Resonance of Peripheral Arterial Disease; NCT00587678).

The effect of ezetimibe on peripheral arterial atherosclerosis depends upon statin use at baseline.

BACKGROUND: Both statins and ezetimibe lower LDL-C, but ezetimibe's effect on atherosclerosis is controversial. We hypothesized that lowering LDL-C cholesterol by adding ezetimibe to statin therapy would regress atherosclerosis measured by magnetic resonance imaging (MRI) in the superficial femoral artery (SFA) in peripheral arterial disease (PAD). METHODS: Atherosclerotic plaque volume was measured in the proximal 15-20 cm of the SFA in 67 PAD patients (age 63 ± 10, ABI 0.69 ± 0.14) at baseline and annually × 2. Statin-naïve patients (n=34) were randomized to simvastatin 40 mg (S, n=16) or simvastatin 40 mg+ezetimibe 10mg (S+E, n=18). Patients already on statins but with LDL-C >80 mg/dl had open-label ezetimibe 10mg added (E, n=33). Repeated measures models estimated changes in plaque parameters over time and between-group differences. RESULTS: LDL-C was lower at year 1 in S+E (67 ± 7 mg/dl) than S (91 ± 8 mg/dl, p<0.05), but similar at year 2 (68 ± 10 mg/dl vs. 83 ± 11 mg/dl, respectively). Plaque volume did not change from baseline to year 2 in either S+E (11.5 ± 1.4-10.5 ± 1.3 cm(3), p=NS) or S (11.0 ± 1.5-10.5 ± 1.4 cm(3), p=NS). In E, plaque progressed from baseline to year 2 (10.0 ± 0.8-10.8 ± 0.9, p<0.01) despite a 22% decrease in LDL-C. CONCLUSIONS: Statin initiation with or without ezetimibe in statin-naïve patients halts progression of peripheral atherosclerosis. When ezetimibe is added to patients previously on statins, peripheral atherosclerosis progressed. Thus, ezetimibe's effect on peripheral atherosclerosis may depend upon relative timing of statin therapy.