Comparison of Aortobifemoral Bypass and Endovascular Treatment for Chronic Infrarenal Abdominal Aortic Occlusion From the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry.

PURPOSE: To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA). MATERIALS AND METHODS: In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term. RESULTS: Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240-345] minutes vs EVT; 159 [100-205] minutes, p<0.001) and length of hospital stay (17 [12-23] days vs 5 [4-13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096). CONCLUSION: Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group.

Peak systolic velocity ratio derived from quantitative vessel analysis for restenosis after femoropopliteal intervention: a multidisciplinary review from Endovascular Asia.

With technological improvements in the endovascular armamentarium, there have been tremendous advances in catheter-based femoropopliteal artery intervention during the last decade. However, standardization of the methodology for assessing outcomes has been underappreciated, and unvalidated peak systolic velocity ratios (PSVRs) of 2.0, 2.4, and 2.5 on duplex ultrasonography have been arbitrarily but routinely used for assessing restenosis. Quantitative vessel analysis (QVA) is a widely accepted method to identify restenosis in a broad spectrum of cardiovascular interventions, and PSVR needs to be validated by QVA. This multidisciplinary review is intended to disseminate the importance of QVA and a validated PSVR based on QVA for binary restenosis in contemporary femoropopliteal intervention.

Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care.

The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.

Experience of on table modified standard catheters for directed arterial and venous thrombolysis.

To describe an on-table modification of standard angiography catheters for use in directed arterial and venous thrombolysis. An angiogram is performed and the length of thrombosed vessel (artery or vein) is measured. A 5 or 6 Fr catheter (preferably straight/multi- purpose/vertebral catheter) is modified on table for use by making multiple holes with 23 G needle. After testing ex vivo with saline injection, the on table modified catheter is placed over a wire into the thrombosed segment of the vessel and thrombolytic agent infusion is commenced utilizing a syringe driver after giving a bolus dose of thrombolytic agent. Median duration of thrombolysis was 24 h in our study. We have utilized this method in twenty thrombosed vessels, without any catheter related complications. In our experience, this modification of a standard catheter as a multi-hole catheter is a readily available, simple, cheap, versatile and effective device for directed thrombolysis.

An endovascular filter to prevent embolization during aortic stenting.

Endovascular procedures carry an intrinsic risk of distal embolization. A large embolus may occlude major vessels with serious consequences. Endovascular procedures in the thoracic aorta may expose the entire visceral and lower limb circulation to this risk. We describe a method of using an endovascular filter to trap large emboli during thoracic aortic stenting using the Wallstent and describe its use in a case of primary aortic mural thrombus.

Vacuum-assisted closure therapy for vascular graft infection (Szilagyi grade III) in the groin-a 10-year multi-center experience.

The aim of the study was to evaluate the benefit of vacuum-assisted closure (VAC) therapy in the management of deep, alloplastic graft infections (Szilagyi grade III) in the groin. From 2000 to 2009, we identified and included in our study 72 deep inguinal infections in 68 patients, involving native as well as synthetic graft or patch material. There were 29 early graft infections (<30 days after implantation) and 43 late infections (≥30 days after implantation). Among these, 17 cases involved native grafts/patches (12 grafts and 5 patches), while 55 cases involved non-native grafts/patches [26 polytetrafluorethylene (PTFE) grafts and 24 Dacron grafts (Haemashield, Meadox Medical, Boston Scientific Corporation, Natick, NY; Gelsoft graft, Vascutek, Inchinnan, Renfrewshire, Scotland, UK; Intervascular, Mahwah, NJ); INVISTA, and 5 Vascu-Guard(™) bovine pericardial patches; Synovis Surgical Innovation]. All patients were treated with multiple wound debridements, graft salvage, sartorius myoplasty, intravenous antibiotics and VAC therapy until thorough surface healing was achieved. Exclusion criteria were an alloplastic graft infection with proximal expansion above the inguinal ligament, blood culture positive for septicaemia or septic anastomotic herald or overt bleeding. Nine months after initiation of therapy, overall, graft/patch salvage was achieved in 61 of 72 (84·7%) cases. Of the native graft/patch group, infected graft material was replaced with an autogenous great saphenous vein graft or patch in four patients (23·5%). In the non-native group, vein or synthetic graft preservation without revision was achieved in 48 of 55 (87·3%) patients. The mean duration of VAC therapy was 16 ± 7·7 days, and postoperative mean hospital stay was 25·3 ± 8·5 days. In 23 of 72 (31·9%) cases, a secondary closure of the wound was achieved; in the other 49 cases, wound healing was achieved by meshed split-thickness skin grafting. Mean wound healing time for all wounds was 24·3 ± 12·5 days. Specific complications during VAC therapy were wound fluid retention in 2 cases and an increased need for analgesics in 12 cases (16·66%). Negative pressure wound therapy (NPWT) has been reported to be useful in the treatment of severe wound infections. Even in the presence of synthetic vascular graft material, NPWT can greatly simplify challenging wound-healing problems leading to wound dehiscence and its sequelae. Our long-term experience demonstrates the safety and effectiveness of VAC therapy in the management of deep graft infections.

Contemporary management of symptomatic primary aortic mural thrombus.

OBJECTIVE: Primary aortic mural thrombus (PAMT) is an uncommon condition but an important source of noncardiogenic emboli with a difficult diagnosis and a high rate of complications, including high mortality. We report our experience of thromboembolic disease from PAMT and review its contemporary management. METHODS: Retrospective analysis of prospectively collected data of all patients who presented with acute occlusion of a limb or visceral vessels between January 2011 and September 2013 was performed. RESULTS: A total of 88 patients presented with acute occlusion of the extremities or visceral arteries. All underwent extensive evaluation for the possible source of the embolism. Of these 88 patients, 19 patients (mean age, 41.2 years; male:female ratio, 1:2.1) were found to have aortic mural thrombus as the source of distal embolism. Thrombus was located in the thoracic aorta in 10 patients, in the perivisceral aorta in three patients, and in the infrarenal aorta in six patients. Thrombus in the thoracic aorta was treated with stent grafts in four patients, bare metal stents in three patients, and anticoagulation alone in two patients. In the suprarenal abdominal aorta, all three patients underwent trapdoor aortic thrombectomy. Infrarenal aortic thrombus was managed by aortobifemoral embolectomy in two patients, aortic stenting in two patients, surgical thrombectomy in one patient, and anticoagulation alone in one patient. Successful treatment, defined as freedom from further embolic events or recurrence of thrombus, was achieved in 14 of 19 patients (76.4%) with a mean follow-up period of 16.2 months (range, 2-28 months). There were four (21%) thrombus-related deaths, all due to primary thromboembolic insults. One patient needed a below-knee amputation because of a recurrent thrombotic episode. CONCLUSIONS: Symptomatic PAMT is an uncommon but important source of noncardiogenic embolus. It appears to occur more frequently in young women. Endovascular coverage of the aortic thrombus, when feasible, appears to be an effective and safe procedure with either stent grafts or closed-cell metal stents. When thrombus is located adjacent to visceral vessels, it should be managed with an open trapdoor thromboembolectomy.

Endovascular management of iatrogenic carotid-jugular fistula presenting as congestive heart failure.

Carotid-jugular arteriovenous fistula (C-J AVF) after inadvertent carotid puncture during internal jugular vein puncture is a rare entity. Previously, majority of reported cases of CJAVF were identified during inadvertent arterial puncture and managed as emergency. We report a delayed presentation of congestive cardiac failure following multiple attempts at securing an internal jugular venous access for dialysis 3 months prior to diagnosis. Carotid-jugular fistula was identified during workup and was successfully treated by endovascular technique with a covered stent.

Endovascular management of venous ulcer in a patient with occluded duplicated inferior vena cava and review of inferior vena cava development.

Duplication of inferior vena cava (IVC) is the most common IVC anomaly. We report a successful iliac vein and collateral stenting for venous decompression in a patient with an occluded right femorocaval graft with a duplicated IVC. We also review the literature of embryological development of IVC.

Reduction internal valvuloplasty is a new technical improvement on plication internal valvuloplasty for primary deep vein valvular incompetence.

OBJECTIVE: We describe a new technique of valve leaflet closure, reduction internal valvuloplasty (RIVAL), to treat primary deep vein valvular incompetence in patients with C6 venous disease. METHODS: The RIVAL method involves excision of redundant valve and suturing of the freshened edge to the wall of the valve station instead of plication at the commissural junctions. Since January 2008, RIVAL has been successfully performed on 44 incompetent deep vein valves in 18 consecutive patients (25 limbs). All patients had C6 venous ulcers of a minimum 3 months' duration. RESULTS: On mean follow-up of 1 year (clinical assessment of venous ulcer healing and color-coded duplex scans at 1, 6, 12, 18, and 24 months) of the 44 valves repaired by reduction valvuloplasty, all 44 valves (100%) maintained full patency. Forty-two valves (95.4%) were competent, achieving a valve closure time <1 second with no reflux at the target valves on Valsalva maneuver in the reverse Trendelenburg and upright positions, and their intervalvular distances were reduced to >60% of preoperative levels. Eighty-eight percent of all ulcers (22 of 25) healed within 9 weeks of surgery without any recurrence in the follow-up period. There was no valve thrombosis or resorption seen with this method. CONCLUSIONS: The RIVAL technique represents a significant advancement over the traditional existing valve plication techniques. It enables accurate anatomic fashioning and suturing of valve cusps and results in excellent competency and ulcer healing rates with fewer complications in our early experience. Further follow-up is anticipated to define its long-term role in the management of C6 venous disease.

Endovascular exclusion of complex postsurgical aortic arch pseudoaneurysm using vascular plug devices and a review of vascular plugs.

We report the management of a patient presenting with haemoptysis due to aortobronchial fistula. He had previously undergone emergency exclusion bypass of a ruptured pseudoaneurysm developing post-aortic coarctation repair. Computed tomography scan showed persistent filling of pseudoaneurysm sac from proximal and distal aortic ligature sites tied during previous exclusion bypass surgery. Successful exclusion of aneurysm was achieved by using 3 vascular plug devices (1 Amplatzer plug II and 2 Amender patent ductus arteriosus occluder devices). We also review types of Amplatzer vascular plugs and their use in peripheral vascular interventions.

Giant adrenal cyst presenting as a diagnostic dilemma: a case report.

Adrenal cysts >10 cm are rare. They generally present as nonspecific abdominal pain and pose a differential diagnostic dilemma to the treating surgeon. A case of a giant adrenal cyst that had presented with abdominal pain and was initially diagnosed as pancreatic pseudocyst is being described here to draw the importance to this entity and to describe the clinical, diagnostic, and therapeutic aspects of the disease.

An audit of foot infections in patients with diabetes mellitus following renal transplantation.

Foot lesions in postrenal transplant diabetics are often overlooked and hence underestimated. An audit of patients attending the authors' department was done. They reviewed the case notes to assess the presentation, clinical profiles, and outcomes of foot infections in patients with diabetes mellitus who received renal transplants at their center. Medical records of 192 diabetic foot patients were assessed, of which 8.8% (n = 17) had a history of previous renal transplantation for diabetic nephropathy. All 17 patients had noninsulin-dependent diabetes of mean duration of 16.2 years (range 7-27 years). Common complications and risk factors were studied. Mean duration to development of foot lesions in renal allograft recipients was 19.7 months (range 6-84 months). The big toe was the most common site of infection. Neuropathy and poor foot care appear to be important factors in the development of these foot lesions. Escherichia coli was the predominant organism on pus culture. Thirty-eight percent of patients needed major amputations; absence of an intact distal vascular tree was associated with a high major amputation rate. Two patients expired due to foot-related septicemia, and healing occurred in the remainder. Mean hospitalization time was 32.7 days. Most patients required more than one admission. The study emphasizes the need for greater attention to lower extremity complications in this patient group.

Pancreatitis in patients with primary hyperparathyroidism.

Records of patients undergoing parathyroidectomy at our institute in the period 1991-2003 were retrospectively analyzed. Pancreatitis was associated in six of 87 patients (6.8%) with primary hyperparathyroidism (PHPT). Pancreatitis was the presenting symptom in five patients, while it developed postoperatively in one case. All patients with a past history of pancreatitis had suffered two or more attacks. All patients had a history of renal stone disease. Four patients also had overt bone disease with multiple fractures. Parathyroid adenoma (4) or carcinoma (1) was the cause in all patients. All five patients who underwent successful parathyroidectomy had resolution of pancreatitis on conservative management and no further attacks during a mean follow up of 28 months (3-84 months). Surgical exploration for parathyroid adenoma failed in one patient; this patient has had further attacks of pancreatitis. Repeat surgical exploration for parathyroidectomy has been advised. Hyperparathyroidism is a rare but treatable cause of pancreatitis. Parathyroidectomy has a salutary effect on the course of pancreatitis.

Histopathological assessment of the liver in cholelithiasis with cholecystitis.

Liver function and histology were studied in 62 patients undergoing elective cholecystectomy. Data from 50 of the cases was subsequently analyzed. Liver function was assessed by biochemical parameters and histological examination of intraoperatively obtained core and wedge liver biopsy. There were no complications associated with the procedure of liver biopsy. Seventy-eight percent of liver biopsies showed some form of abnormality, the commonest being mild portal tract infiltration. Eighteen percent of patients had severe histological abnormalities. Fourteen percent of bile samples were infected. No correlation was found among age, symptom duration, liver function tests, and histological appearance. Biliary infection was associated with a significant incidence of fatty change and inflammatory cell infiltration of parenchyma. We observed a high rate of abnormal liver histology of unknown clinical significance in patients of calculous cholecystitis. These changes are not reflected in commonly performed tests of liver function. Intraoperative liver biopsy is a safe and sensitive method to detect liver abnormalities.