Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Assessment of behavioral determinants influencing success of supervised exercise therapy in patients with intermittent claudication: A cross sectional survey.

BACKGROUND: Supervised exercise therapy is the first step in treatment of intermittent claudication. However, adherence to supervised exercise therapy is low. Limited access and reimbursement issues are known reasons, though lack of motivation is often leading. Behavioral determinants influencing motivation and thus adherence to supervised exercise therapy remain to be investigated. In this study we sought to determine which behavioral determinants would be of influence on the long-term adherence of supervised exercise therapy. METHODS: 200 patients, newly diagnosed with peripheral arterial disease Rutherford classification II-III, were sent a questionnaire to assess motivation and behavior with regard to supervised exercise therapy. The questionnaire was constructed using the I-CHANGE model for explaining motivational and behavioral change. Baseline characteristics were acquired from medical records. Alpha Cronbach's was calculated to test reliability of the questionnaire. RESULTS: 108 (54%) patients returned their questionnaire. A total of 79% patients followed supervised exercise therapy. Patients who increased their walking distance after supervised exercise therapy have significantly greater knowledge (p = 0.05), positive attitude (p = 0.03) and lower negative attitude (p = 0.01). Patients with a higher self-efficacy remained significantly more active after participating in supervised exercise therapy (p = 0.05). CONCLUSION: Increasing the determinants knowledge, attitude and self-efficacy will improve adherence to supervised exercise therapy and result in delayed claudication onset time.

A randomised controlled trial comparing compression therapy after radiofrequency ablation for primary great saphenous vein incompetence.

BACKGROUND: Optimal duration of leg compression after venous ablation remains unclear. This randomised controlled trial evaluates 4 h compared to 72 h of leg compression. METHODS: Patients were randomised to 4 or 72 h of leg compression after radiofrequency ablation of the great saphenous vein. Primary outcome was change in leg volume after 14 days. Secondary outcomes were postoperative pain, complications and time to full recovery. RESULTS: Patients wearing compression stockings for 4 h after treatment had a 64 mL (95%CI: - 23 to + 193) reduction in leg volume, compared to an increase of 21 mL (95%CI: 8.33-34.5) in patients wearing compression stockings for 72 h (P = 0.12). Patients wearing compression stockings for 4 h experienced fewer complications (16% vs. 33%, P = 0.05). Postoperative pain and time to full recovery did not differ significantly. CONCLUSION: Wearing compression stockings for 4 h is non-inferior in preventing leg oedema as wearing compression stockings for 72 h.

Contrast Induced Nephropathy and Long-term Renal Decline After Percutaneous Transluminal Angioplasty for Symptomatic Peripheral Arterial Disease.

OBJECTIVE/BACKGROUND: Administration of iodinated contrast media during endovascular procedures for peripheral arterial disease (PAD) may cause contrast induced nephropathy (CIN). The aim of the present study was to establish the incidence of CIN after these procedures and to study its association with long-term loss of kidney function, cardiovascular events, and death. METHODS: Consecutive patients first presenting with symptomatic PAD (Rutherford classification II-VI) who were treated with an endovascular procedure were included in this prospective observational cohort study. CIN was defined as >25% increase of serum creatinine concentration from baseline at 5 days after the intervention. RESULTS: Some 337 patients were included with a mean estimated glomerular filtration rate (eGFR) of 67 mL/minute. Thirteen percent (95% confidence interval [CI] 9-16) of these patients developed CIN after endovascular interventions for PAD. One year after treatment, eGFR was reduced by 12.4 mL/minute (95% CI 8.6-16.2) in patients with CIN compared with 6.2 mL/minute (95% CI 4.9-7.0) in patients without acute kidney injury (p < .01). After correction for potential confounders, CIN was associated with a 7.8 mL/minute (95% CI 4.5-11.0) reduction of eGFR at 1 year after endovascular intervention (p < .01). Furthermore, patients with CIN were at increased risk of long-term cardiovascular events and mortality. CONCLUSION: Exposure to iodinated contrast media during endovascular procedures for symptomatic PAD frequently results in CIN. Patients with CIN are at increased risk of long-term loss of renal function, cardiovascular events, and death.

Treatment of aortic graft infection by in situ reconstruction with Omniflow II biosynthetic prosthesis.

Currently available conduits for in situ reconstruction after excision of infected aortic grafts have significant limitations. The Omniflow II vascular prosthesis is a biosynthetic graft associated with a low incidence of infection that has succesfully been used in the treatment of infected infrainguinal bypass. We report on the first use of the Omniflow II prosthesis for in situ reconstruction after aortic graft infection.A bifurcated biosynthetic bypass was created by spatulating and anastomosing two 8-mm tubular Omniflow II grafts. This bypass was used for in situ reconstruction after excision of infected aortic grafts in three cases. After a mean follow-up of 2.2 years, no occlusion, degeneration, or rupture of the Omniflow II grafts was observed. Although one patient suffered from graft reinfection, the bypass retained structural integrity and no anastomotic dehiscence was observed.Treatment of aortic graft infection by in situ reconstruction with the Omniflow II vascular prosthesis is feasible. Its resistance to infection and off-the-shelf availability make this graft a promising conduit for aortoiliac reconstruction.

Duplex-guided percutaneous transluminal angioplasty in iliac arterial occlusive disease.

BACKGROUND: Chronic renal insufficiency (CRI) is a growing global problem. PTA can be performed without nephrotoxic contrast, utilizing Doppler-ultrasound (Duplex) guidance. Duplex-guided infra-inguinal interventions and access-related interventions have been reported. Duplex-guided iliac interventions have not been performed to any extent because of the anatomic location. In our study we evaluated the safety and efficacy of Duplex-guided percutaneous transluminal angioplasty (DuPTA) in iliac arteries. METHODS: From June 2012 until February 2013, 31 patients (35 iliac lesions), underwent DuPTA. Indications ranged from Rutherford 3 to 5. Preoperative evaluation included Ankle Brachial Index (ABI), Duplex and MRA. Procedural success was defined as crossing the lesion with a guidewire and dilating or stenting the lesion. Clinical success was defined as 50% reduction in peak systolic velocity (PSV) or clinical improvement. PSV was evaluated after PTA, then at 2 weeks. Clinical results were assessed 2 weeks after the procedure. RESULTS: Procedural success was achieved in 94% of patients (33/35), all of whom also had clinical success. Post-procedural PSV reduction showed an average improvement of 63% (431 cm/s to 153 cm/s). Mean preoperative ABI was 0.72 and improved to 0.88 postoperatively. CONCLUSIONS: PTA using Duplex-guidance in significant iliac stenosis is a safe method with major advantages in patients at high risk for developing contrast-induced nephropathy.

Outcome of patients with ruptured abdominal aortic aneurysm after cardiopulmonary resuscitation.

PURPOSE: Ruptured aneurysm of the abdominal aorta (RAAA) is a condition associated with high mortality rate. If Cardiopulmonary Resuscitation (CPR) is required, outcome is considered even worse. The aim of this study was to assess the effect of CPR on 30-day mortality of RAAA patients. Furthermore the Hardman index was evaluated. METHODS: 109 patients with RAAA during a 5 year period (2001-2005) were analysed retrospectively. 30-day mortality, the presence of CPR and Hardman risk factors were recorded. The presence of CPR and the Hardman index were related to clinical outcome. RESULTS: 104 patients were included in our analysis. Eighteen patients received CPR. Overall 30-day mortality was 40%. Patients receiving CPR had a higher mortality rate than patients who did not (89% vs. 30%, p <0.0001). Patients receiving CPR prior to surgery had a mortality rate of 100% (n = 12). In patients with a Hardman Index of < or = 1, 2 and > or = 3 the 30-day mortality was respectively 15%, 47% and 81%. CONCLUSION: Requirement of CPR has a detrimental effect on RAAA-patient outcome. Patients receiving CPR prior to surgery have no survival chance. We advocate that surgery in these patients should not be undertaken. Hardman Index has a predictive value concerning 30-day mortality.

[Diagnostic image (340). A woman with painful ankles. Bilateral distal fibula stress fractures with callus formation]. / Diagnose in beeld (340). Een vrouw met pijnlijke enkels. Beiderzijdse stressfracturen van het distale deel van de fibula.

A 44-year-old woman was admitted with swelling and pain in both ankles since an active holiday one month earlier. She had bilateral distal fibula stress fractures with callus formation.

[Diagnostic image (313). A woman with peracute abdominal pain in the right lower quadrant]. / Diagnose in beeld (313). Een vrouw met peracute buikpijn rechtsonder. Bloeding uit een corpus rubrum.

A 29-year-old woman presented with peracute pain in the right lower quadrant of her abdomen, which at diagnostic laparoscopy appeared to be related to hematoperitoneum caused by bleeding ofa corpus rubrum.

[Diagnostic image (308). A man with dyspnoea after a soccer accident]. / Diagnose in beeld (308). Een man met kortademigheid na een voetbalongeluk.

During a soccer match, the foot of a goal keeper collided with the right thoracoabdominal area of a player, who afterwards suffered from dyspnoea caused by a ruptured liver.

Current status and prospects of clinical proteomics studies on detection of colorectal cancer: hopes and fears.

Colorectal adenocarcinoma (CRC) is the third most common type of cancer and the fourth most frequent cause of death due to cancer worldwide. Given the natural history of CRC, early diagnosis appears to be the most appropriate tool to reduce disease-related mortality. A field of recent interest is clinical proteomics, which was reported to lead to high sensitivity and specificities for early detection of several solid tumors. This emerging field uses mass spectrometry-based protein profiles/patterns of easy accessible body fluids to distinguish cancer from non-cancer patients. These discrepancies may be a result of: (1) proteins being abnormally produced or shed and added to the serum proteome, (2) proteins clipped or modified as a consequence of the disease process, or (3) proteins subtracted from the proteome owing to disease-related proteolytic degradation pathways. Therefore, protein pattern diagnostics would provide easy and reliable tools for detection of cancer. This paper focuses on the current status of clinical proteomics research in oncology and in colorectal cancer especially, and will reflect on pitfalls and fears in this relatively new area of clinical medicine, which are reproducibility issues and pre-analytical factors, statistical issues, and identification and nature of discriminating proteins/peptides.

[Basal cell naevus syndrome as the cause of a chronic foot ulcer]. / Basaalcelnaevussyndroom als oorzaak van een chronisch voetulcus.

A 46-year-old man presented to the surgery outpatient clinic with an ulcer on top of his left foot. He had previously been diagnosed with basal cell naevus syndrome but had withdrawn from follow-up. His foot showed a deep ulcerating defect accompanied by profound necrosis extending to the metatarsophalangeal joints. There was a nodular skin defect over the first metatarsophalangeal joint, which was shown by histopathology to be a basal cell carcinoma, and the ulcer was bordered by a raised wall. Further physical examination revealed more than 200 dermal lesions which were identified by the dermatologist who was called in for consultation as basal cell carcinomas; multiple depressions due to abnormal local keratinisation were also seen on the palms of the hands and the soles of the feet. These findings led to a diagnosis of 'basal cell naevus syndrome'. The patient was treated by amputation of the lower leg followed by excision and curettage of the remaining basal cell carcinomas. At the time of the last follow-up, the patient was being checked periodically in the dermatology outpatient clinic. Basal cell naevus syndrome is a rare autosomal dominant hereditary disease. The prevalence is estimated to be between 1 in 57,000 and 1 in 164,000. Basal cell naevus syndrome is generally caused by a mutation in the 'patched homolog' (PTCH)-I gene, located on chromosome 9q22.3. Although the syndrome affects multiple organ systems, the most characteristic of this disorder is the appearance of multiple basal cell carcinomas.

[Diagnostic image (288). A woman with lower right abdominal pain]. / Diagnose in beeld (288). Een vrouw met pijn rechts onder in de buik.

A woman with lower right abdominal pain was diagnosed with a nail perforating the appendix. She must have swallowed this nail in infancy.

Human IgA activates the complement system via the mannan-binding lectin pathway.

The recently identified lectin pathway of the complement system, initiated by binding of mannan-binding lectin (MBL) to its ligands, is a key component of innate immunity. MBL-deficient individuals show an increased susceptibility for infections, especially of the mucosal system. We examined whether IgA, an important mediator of mucosal immunity, activates the complement system via the lectin pathway. Our results indicate a dose-dependent binding of MBL to polymeric, but not monomeric IgA coated in microtiter plates. This interaction involves the carbohydrate recognition domain of MBL, because it was calcium dependent and inhibited by mannose and by mAb against this domain of MBL. Binding of MBL to IgA induces complement activation, as demonstrated by a dose-dependent deposition of C4 and C3 upon addition of a complement source. The MBL concentrations required for IgA-induced C4 and C3 activation are well below the normal MBL plasma concentrations. In line with these experiments, serum from individuals having mutations in the MBL gene showed significantly less activation of C4 by IgA and mannan than serum from wild-type individuals. We conclude that MBL binding to IgA results in complement activation, which is proposed to lead to a synergistic action of MBL and IgA in antimicrobial defense. Furthermore, our results may explain glomerular complement deposition in IgA nephropathy.