Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms.

BACKGROUND: The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. METHODS: In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. RESULTS: A total of 928 cases with intact aortoiliac aneurysms had an elective (n = 882) or urgent (n = 46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P = 0.01). Open repair (n = 514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n = 414, odds ratio [OR] 7.1, P = 0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P = 0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR = 6.0, P = 0.001), preoperative angiography (7% vs. 1.6%, OR = 4.5, P = 0.01), special aneurysm presentation (10.9% vs. 1.5%, OR = 8.1, P < 0.001), concomitant major procedures (19% vs. 1.7%, OR = 14.0, P < 0.001), serious intraoperative complications (9.1% vs. 1.5%, OR = 6.6, P = 0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P < 0.001), and procedure duration (270 and 150 min for cases with and without mortality, respectively, P < 0.001). Open repair (OR = 4.5, P = 0.05), special aneurysm presentation (OR = 6.58, P = 0.001), and concomitant major procedures (OR = 14.3, P < 0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P = 0.87) and VSGNE score (P = 0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. CONCLUSIONS: Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

Use of the Covera Stent Graft for the Treatment of Dysfunctional or Thrombosed Arteriovenous Grafts: A Retrospective Analysis of 64 Patients.

PURPOSE: To retrospectively evaluate the safety and effectiveness of the Covera stent graft (SG) for the treatment of dysfunctional or thrombosed arteriovenous grafts (AVGs). MATERIALS AND METHODS: Within 29 months (February 2016-August 2018), 79 patients underwent Covera SG placement in the authors' department for the treatment of dysfunctional AVGs. Data were available for 64 patients who underwent 64 procedures, using 64 devices. Minimum follow-up was 6 months, unless reintervention occurred. Mean follow-up was 277 days (6-923 days). Treatment characteristics were 51 cases with venous-graft anastomosis (VGA) stenosis (79.7%), 13 cases of puncture zone stenosis (20.3%), 14 cases of in SG stenosis (21.9%), 8 cases of pseudoaneurysm treatment (12.5%) (1 treatment area might have had more than 1 characteristic). Thirty-six patients presented with thrombosis (56.2%), and 31 of 64 case were de novo treatment areas (48.4%). Primary outcome measurements were technical success and post-intervention primary patency (PIPP) at 6 months, whereas secondary outcome measurements included factors influencing primary outcome. RESULTS: Technical success was 100%. Median PIPP was 336 days, and 73.6% of treatment areas were patent at 6 months. There were no significant differences in terms of PIPP when de novo treatment areas were compared with restenotic areas (519 vs. 320 days, respectively; P = .1); patients who presented with versus those who presented without thrombosis (320 vs. 583 days, respectively; P = .07); puncture zone stenosis or elsewhere (329 vs. 686 days, respectively; P = .52); and VGA stenosis or elsewhere (336 vs. 335 days, respectively; P = .9). CONCLUSIONS: Use of the Covera SG for AVG treatment was safe and effective in every type of treatment area presented in this retrospective analysis.

Improved effectiveness of the repositionable GORE EXCLUDER AAA endoprosthesis featuring the C3 delivery system compared with the original GORE EXCLUDER AAA endoprosthesis for within the instructions for use treatment of aortoiliac aneurysms.

OBJECTIVE: To compare two endograft types, the original GORE EXCLUDER AAA endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) with the repositionable GORE EXCLUDER featuring the C3 delivery system, which allows repositioning of the proximal part of the graft to achieve accurate placement in relation to the renal arteries, in unselected patients with aortoiliac aneurysms. In a second nested, substudy we investigated the relative effect of the standard Gore and Gore Dryseal introducer sheaths on intraoperative transfusion needs. METHODS: We retrospectively analyzed prospectively collected information. The primary composite outcome measure was the intraoperative misdeployment or migration of the endograft's main body, proximally or distally to the renals (leading to technical failure or requiring either placement of aortic cuff extenders or conversion to open repair). Secondary outcome measures included the composite long-term event of rupture and/or type I/III endoleak. RESULTS: A total of 313 consecutive patients (303 males; median age, 73 years) had either an original GORE EXCLUDER device (n = 174) or the new device (n = 139) placed between 2004 and 2011 and 2011 and 2017, respectively, to treat an infrarenal aortoiliac aneurysm or an isolated common iliac artery aneurysm. The primary composite outcome measure occurred more often in patients who had the original GORE EXCLUDER device placed (10.9% vs 3.6% for the new device; odds ratio, 0.30; 95% confidence interval, 0.11-0.84; P = .016), confirmed by multivariate logistic regression analysis. This difference between the two groups was exclusively driven by distal misdeployment or migration of the endograft (10.3% vs 2.9% for the new device; P = .01), mostly requiring aortic extender placement. Intraoperative blood transfusion rates were lower in patients who had the GORE Dryseal introducer sheath used (1.1% vs 18.9% for the original GORE introducer sheath; OR, 0.05; 95% confidence interval, 0.006-0.35; P < .001). At a mean follow-up of 1.7 years (maximum, 13 years), 11 patients developed the composite event. On univariate Cox analysis, significant predictors included female gender (P = .003), absence of dyslipidemia (P = .023), the primary outcome measure (P = .006), and failure to cannulate (P = .009), but not device type or other variables. On multivariate Cox regression, female gender (hazard ratio, 37; P < .001), chronic obstructive pulmonary disease (hazard ratio, 3.99; P = .045), the primary outcome measure of the study (hazard ratio, 8.9; P = .002), and failure to cannulate (hazard ratio, 43; P = .003) were all independent predictors. CONCLUSIONS: Our study has demonstrated that the repositionable GORE EXCLUDER has important safety characteristics compared with the original device and equivalent long-term effectiveness. Additional benefit was obtained with the use of the Gore Dryseal introducer sheath.

Acute Effects of Graduated Elastic Compression Stockings in Patients with Symptomatic Varicose Veins: A Randomised Double Blind Placebo Controlled Trial.

OBJECTIVES: To investigate the effectiveness of graduated elastic compression stockings (GECS) below the knee in improving symptoms in patients with varicose veins in the absence of high quality evidence. METHODS: This was a randomised double blind placebo controlled trial. Thirty patients with no experience of elastic stockings, presenting with primary varicose veins causing calf pain or aching were randomised to a GECS (18-21 mmHg at the ankle level, n=15) or a placebo stocking (0 mmHg, n=15). Pain or aching of the index leg after 1 week was the primary outcome measure. In patients with bilateral varicose veins the leg with the most severe pain/aching was considered. Other defined symptoms were secondary outcome measures. All symptoms were scored on a visual analogue scale (VAS). RESULTS: The two study groups were well balanced at baseline. At the completion of the study after 1 week, GECS were more effective than placebo stockings in reducing pain or aching (VAS score 1.7±3.0 vs. 4.5±2.8 for placebo, p=.02), while non-significant trends were observed for some of the remaining symptoms of the index leg, including feeling of swelling (VAS score 0.9±1.9 vs. 3.3±3.5 for placebo), paraesthesiae (VAS score 0.2±0.6 vs. 2.1±3.1 for placebo), and the number of symptoms other than pain or aching (1.3±1.1 vs. 2.8±1.7 for placebo). Number needed to treat (95% CI) for a 50% or complete improvement of pain or aching in the index leg was 2 (95% CI 1.2-5.5) and 2 (95% CI 1.2-5.3), respectively. Mean daily use of the placebo stockings and GECS was 8.0 hours and 10.2 hours, respectively (p=.13). CONCLUSIONS: Among patients with varicose veins, GECS seem effective in ameliorating symptoms, particularly pain or aching, compared with placebo stockings after 1 week of use. Long-term studies are justified.

WaterSpy: A High Sensitivity, Portable Photonic Device for Pervasive Water Quality Analysis.

In this paper, we present WaterSpy, a project developing an innovative, compact, cost-effective photonic device for pervasive water quality sensing, operating in the mid-IR spectral range. The approach combines the use of advanced Quantum Cascade Lasers (QCLs) employing the Vernier effect, used as light source, with novel, fibre-coupled, fast and sensitive Higher Operation Temperature (HOT) photodetectors, used as sensors. These will be complemented by optimised laser driving and detector electronics, laser modulation and signal conditioning technologies. The paper presents the WaterSpy concept, the requirements elicited, the preliminary architecture design of the device, the use cases in which it will be validated, while highlighting the innovative technologies that contribute to the advancement of the current state of the art.

Evaluation of a new paclitaxel-coated balloon catheter in an in vivo porcine peripheral venous model: Feasibility, safety, and drug deliverability.

PURPOSE: To evaluate in vivo the feasibility, safety, and paclitaxel (PTX) deliverability of a newly developed non-commercially available Paclitaxel-Coated Balloon (PCB) catheter in the swine healthy peripheral vein model. MATERIALS AND METHODS: In total 12 PCBs were deployed in 12 venous segments. Primary feasibility endpoint was the successful application of the devices to the veins of the animals. Primary efficacy endpoint was the determination of the drug content in the venous tissue at 24 h and 7 days after balloon expansion, as assessed by analysis of the vein tissue with High Performance Liquid Chromatography (HPLC) coupled with tandem mass spectrometry. Primary safety endpoint was freedom from any major adverse event. Secondary endpoint was the investigation of any independent factor affecting the primary endpoints. RESULTS: Paclitaxel was detected in five out of six tissue samples 24 h post-intervention and five out of six tissues at 7 days following the procedure (10 tissue samples out of 12). The mean weight of tissue that was examined was 0.20604 ± 0.29822 g (range: 1.02823-0.03377 g) and the mean PTX concentration detected was 8.4 ± 13.1 µg/g (range: 0-36.1 µg/g). The average drug content detected at 24 h (17.1 ± 17.1 µg/g) was numerically superior, but non-statistically significant, compared to 7 days (3.1 ± 3.6 µg/g). An average of 33.8% of the drug remained on the balloon after retrieval. According to the multiple linear regression analysis, there was no significant correlation between transition time, PTX remaining on the balloon, time of analysis (24 h/7 days) and PTX tissue concentration. No abnormalities were noted during autopsy. CONCLUSION: The newly developed PCB successfully delivered within the healthy venous wall a dose of Paclitaxel that inhibits neointimal hyperplasia. No safety issues were raised at short-term follow-up.

A Case of Reconstruction of a Type IIIc Open Tibial Fracture with Bone Loss and Warm Ischemia Time of 13 Hours: Quality of Life and Review of the Literature.

BACKGROUND The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. CASE REPORT We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. CONCLUSIONS The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.

A Systematic Review and Meta-Analysis of Randomized Trials Comparing Two-Stage with One-Stage Brachio-Basilic Vein Fistulas.

PURPOSE: There is currently debate if brachio-basilic vein fistula (BBVF) should be performed as a one-stage or two-stage procedure. The aim of the present study was to perform a systematic review and meta-analysis on BBVF staging. MATERIALS AND METHODS: On February 25, 2016, a search for randomized-controlled trials (RCTs) on BBVF procedures was performed in MEDLINE and Scopus databases. Meta-analyses were performed with fixed-effect or random-effects models as appropriate with risk ratios (RRs). The primary efficacy and safety outcome measures were BBVF maturation and development of complications, respectively. Specific types of complications, including loss of functional secondary patency and long-term complications were all secondary outcome measures. RESULTS: We identified three RCTs reporting on 126 patients. Maturation failure of two-stage BBVFs (3/47, 6.4%) was less frequent than one-stage BBVFs (16/79, 20.3%; RR, 0.27; P=0.02). Complication rates of two-stage and one-stage BBVFs were similar (RR, 0.80; P=0.54), but on sensitivity analysis these were less likely to occur with two-stage BBVFs (37% vs. 69% for one-stage BBVFs; RR, 0.57; P=0.03). Two-stage BBVFs were less likely to lose their functional secondary patency (21.3% vs. 31.6% for one-stage BBVFs; RR, 0.61; P=0.11). This non-significant trend became significant (RR, 0.36; P=0.02) on sensitivity analysis. There was no difference in specific complication rates of the two study groups. CONCLUSION: Among candidates for BBVF fistula, there is evidence to suggest that two-stage BBVFs achieve higher maturation rates compared to one-stage BBVFs. The evidence for difference in long-term secondary patency is less robust, calling for further research.

Successful Resection of a Large Carotid Body Tumor Masquerading Complete Encasement of the Internal Carotid Artery on Preoperative Imaging.

A 41-year-old woman presented with a large painful and tender mass of the left side of her neck located just below the angle of the mandible. She was also complaining of frequent attacks of symptoms ranging from dizziness upon resuming the erect position to frank syncope. Color-coded duplex showed a large well-vascularized vascular mass at the level of the carotid bifurcation, suggesting the diagnosis of a carotid body tumor (CBT). A computerized tomographic angiography confirmed the diagnosis of a CBT, which measured 5.7 cm in its craniocaudal axis. The tumor appeared to encase the internal carotid artery (ICA) at the level of its origin, indicating the presence of a Shamblin group 3 tumor. During surgery, the CBT seemingly encased the ICA; however, it was successfully taken off the ICA, by establishing an adventitial dissection place, obviating the need for arterial resection and replacement. A brief intraoperative episode of cardiac arrest was successfully managed. Postoperative course was uneventful, and all symptoms were cured. Pathology confirmed the clinical diagnosis and did not show malignancy. In conclusion, meticulous surgical techniques can spare the ICA from removal or inadvertent injury during CBT surgery and reduce the morbidity often associated with the resection of large or advanced tumors but also cure atypical patient symptoms.

Surgical and endovascular revision of brachio-basilic vein fistula.

PURPOSE: The brachio-basilic vein fistula (BBVF) is currently the third vascular access option for patients on hemodialysis, following radio-cephalic and brachio-cephalic arterio-venous fistulas. Like all types of hemodialysis vascular access, a variety of procedures may have to be performed in order to maintain long-term use of the BBVF. The aim of the present study was to perform a literature review of endovascular or surgical revisions of BBVFs. METHODS: On Pubmed search, 676 records were obtained and reviewed for relevance with the aim of the search. RESULTS: A variety of endovascular and surgical revision techniques has been described to manage BBVF poor maturation, dysfunction manifested as failing BBVF (most often the result of a stenosis at the transposed/swing segment), thrombosis, aneurysm formation and hemodialysis access-induced hand ischemia (steal syndrome). The role of revision is crucial in BBVF maintenance, taking into account that around 70% of these fistulas will require some intervention by 18 months and as a result of revision, secondary patency is preserved in the vast majority, according to the results of one study. Endovascular revision is the treatment of choice for most cases of BBVF dysfunction or thrombosis, with redo surgery reserved for failures of endovascular techniques or other specific indications. CONCLUSIONS: BBVF revision, more often in the form of endovascular surgery, plays a crucial role in BBVF maintenance and its continued use for hemodialysis, necessary for reducing graft and catheter use and the associated morbidity.

Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms: A Comparative Study and Meta-Analysis of the Literature.

OBJECTIVES: Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature. METHODS: Twenty-seven patients with an intact IAAA operated on during a 21-year period were included. RESULTS: Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units (P = .001), procedure duration (P < .001), and postoperative hospitalization (P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR (P = 1.00). CONCLUSIONS: Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.

Randomized controlled trial comparing primary and staged basilic vein transposition.

OBJECTIVE: It is unclear if brachio-basilic vein fistula should be performed as a primary or staged procedure, particularly for smaller basilic veins. Our aim was to report on a randomized controlled trial comparing these two techniques. METHODS: Sixteen patients with a basilic vein ≥2.5 mm were randomized into primary transposed brachio-basilic vein (TBBV) fistula (n = 9) and staged TBBV fistula (n = 7). Patients with basilic veins enlarged by previous arteriovenous fistulas were excluded. Baseline characteristics of the two study groups, including vein size, were comparable (median basilic vein diameter 3.5 mm, range 2.8-4.1 mm). The staged group had a brachio-basilic vein fistula performed first followed by the transposition procedure performed at least 6 weeks later to allow the basilic vein to enlarge. TBBV fistula maturation at 10 weeks, primary, assisted-primary, and secondary patency were the primary outcome measures. Early failures were included in the calculation of patency rates. RESULTS: Transposed brachio-basilic vein fistula maturation rate after primary procedures (3/9, 33%) was lower compared to maturation rate after staged procedures (7/7, 100%, P = 0.011, Fisher's exact test), which led to premature termination of the trial. Time to hemodialysis [median (interquartile range)] of primary and staged procedures was 54 (51.5-113.5) days and 97 (93-126) days, respectively (P = 0.16). One-year primary and assisted-primary patency rates of primary and staged procedures were equivalent (44 vs 57%, P = 0.76 and 44 vs 71%, P = 0.29, respectively); however, there was a trend toward a better 1-year secondary patency after staged procedures (86 vs 44% for primary procedures, P = 0.09). CONCLUSIONS: Among candidates for TBBV fistula with a small basilic vein, staged transposition achieves higher maturation rates compared to primary procedures, a difference reflected in long-term secondary patency. TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NCT01274117.

Retained subintimal pellet in a carotid artery.

A shotgun pellet is depicted in the present image in a carotid artery under the intima, which remained intact without local complications for up to six months. There is lack of data regarding the natural history of such a carotid pellet, but the experience from the myocardium is that, in the absence of infection, completely embedded missiles are usually asymptomatic, tolerated well and may be left in place.

Seasonal variation in the incidence of superficial venous thrombophlebitis.

INTRODUCTION: Previous studies have demonstrated an increased frequency and severity of symptoms due to varicose veins during summer. However there is no data on their complications, including superficial venous thrombophlebitis (SVT). The aim of this study was to test the hypothesis that SVT follows a seasonal pattern. MATERIALS AND METHODS: During the two-year period between January 2007 and December 2008, inclusive, 123 patients with SVT were evaluated, including 60 females and 63 males. In 8 patients (6.5%) an additional and/or other predisposing factor was present. On presentation, SVT was complicated by thrombus extension to the proximal deep system in 5 cases (4.1%); above-knee SVT was present in 4 of these 5 cases. RESULTS: SVT occurred more often during the months of May through October (monthly incidence of 7.3 cases) compared to remaining of the year (monthly incidence of 2.9 cases). SVT showed a peak in June and July with 33.3% of all SVTs occurring during these two months (monthly incidence of 10.25 cases). Using time-series statistics SVT occurrence showed a periodical seasonal pattern (p=0.003). Although a seasonal pattern was evident in all patient subgroups, this was significant only in males and patients with below-knee SVT. CONCLUSIONS: SVT showed a clear seasonal pattern of occurrence, with a significant rise during summer time. Although a possible explanation of this observation could be poor patient compliance and suboptimal usage of elastic stockings during the hot Mediterranean summer, further studies to investigate the cause, clinical significance and preventive methods of this complication are justified.

Aortic angiosarcoma with cutaneous metastases.

Primary aortic tumors are rare and include a variety of histologic types, including aortic angiosarcomas, with less than 100 cases being reported since the first description of these tumors in 1873. The diagnosis of aortic angiosarcoma is usually confirmed by postoperative histopathologic examination or postmortem study. We present a case of primary aortic angiosarcoma presenting with intermittent claudication and radiologic findings of aortoiliac atherosclerotic disease treated initially with stenting; lower extremity embolic skin metastases developed during follow-up that prompted resection of the aortic bifurcation and restoration of the arterial continuity with a bypass. Despite postresection recurrence, a 3-year survival was achieved with aggressive multidisciplinary management.

Preoperative evaluation for vascular access creation.

In an effort to increase the prevalence of arteriovenous fistulae (AVF), ultrasound vessel mapping (USVM) and upper extremity venography (UEV) have been suggested; however, the effectiveness of their combined use remains unknown. We studied the effect of such a combined protocol on arteriovenous (AV) access type change compared with physical examination alone. Consecutive patients with chronic kidney disease (n = 137) after an initial estimation of the AV access type, based on physical examination, had USVM and UEV to detect vascular pathology that could potentially alter the original plan. USVM changed the preoperative plan in 31 (22.6%) patients; this was 36.7% (n = 18) in diabetics compared with 14.8% (n = 13) in nondiabetics (p < .001). Patients for whom USVM changed the type of planned AV access had been on hemodialysis significantly longer (2.7 years vs 0.9 years; p < .001). Venography identified 18 patients with central vein stenosis that led to a site change in 12 of them. Significant venous stenosis in patients with a history of two or more central catheters placed and patients without such a history was 93% and 1%, respectively. In eight patients, intraoperative findings dictated AV graft placement or creation of a central AVF. The original plan was revised in 31%, and this rate was similar for distal AVF, central AVF, and AV grafts (38%, 26%, and 43%, respectively; all p > .05). The 30-day patency rate was 92.2%. A significant proportion of patients have vascular pathology severe enough to alter the access type as suggested by physical examination alone. USVM should be routinely performed, whereas UEV should be selectively performed in patients with a history of surgery or instrumentation of their central veins.