Long-term clinical outcomes of arterial bypass, and the factors independently associated with the primary patency of arterial bypass in patients with suprainguinal arterial occlusion.

INTRODUCTION: Aortoiliac occlusive disease and iliofemoral occlusion are impact patient quality of life, cause limb loss and mortality. The aim of this study was to investigate the long-term clinical outcomes of arterial bypass, and the factors associated with the outcomes. METHOD: This retrospective chart/image review included all types of arterial bypass procedures performed for suprainguinal arterial occlusion during January 2004 to December 2017. The primary outcome was the primary patency. The secondary outcomes were the secondary patency, amputation-free survival, overall survival and the factors associated with the outcomes. RESULT: A total of 135 patients (107 males) were included. The median age was 65 years. The 1-year, 5-year, and 10-year primary patency rates were 74.3%, 65.7%, and 55.6%, respectively, with independent predictors of poor outcomes being underlying cerebrovascular disease (p = 0.003) and postoperative graft infection (p = 0.016). Secondary patency rates at 1-year, 5-year, and 10-year intervals were 90.1%, 87.1%, and 77.8%, respectively, with independent predictors of poor outcomes being underlying cardiovascular disease (p = 0.013) and postoperative acute kidney injury (p = 0.010). Amputation-free survival rates at 1-year, 5-year, and 10-year intervals were 77.1%, 71.6%, and 66.0%, respectively, with the independent predictor of poor outcome being preoperative foot infection (p = 0.013). Overall survival rates at 1-year, 5-year, and 10-year intervals were 84.4%, 58.6%, and 35.3%, respectively, with independent predictors of poor outcomes being chronic kidney disease (p = 0.030) and postoperative myocardial infarction (p = 0.018). However, antiplatelet therapy emerged as an independent predictor of favorable overall survival outcomes (p = 0.034). CONCLUSION: Our results showed the primary patency rates of arterial bypass to be relatively low at our center; however, most grafts could be saved with high secondary patency. Both disease-associated factors and patient condition-associated factors were found to influence the outcomes of this fragile patient population.

Navigating Challenges in the Endovascular Treatment of Asymptomatic Aortoiliac Aneurysms: A 10-Year Comparative Analysis.

BACKGROUND: Treating an abdominal aortoiliac aneurysm (AAIA) with endovascular methods can be challenging when the internal iliac artery (IIA) is involved. Embolizing the IIA and extending the limb to the external iliac artery (IIAE + EE) to prevent a type 2 endoleak may lead to pelvic ischemic complications. To avoid these complications, strategies that preserve the IIA, such as the bell-bottom technique (BBT) and the iliac branch device (IBD), have been proposed. This study aims to compare the outcomes of these three endovascular approaches for AAIA. METHODS: Between January 2010 and December 2019, 174 patients with asymptomatic AAIA were enrolled in this retrospective analysis. They were divided into two groups: 81 patients underwent non-IIAE procedures, and 93 patients underwent IIAE procedures. The iliac limb study group consisted of 106 limbs treated with the BBT, 113 limbs treated with the IIAE + EE, and 32 limbs treated with the IBD. The primary outcomes included the 30-day mortality rate and intraoperative limb complications. The secondary outcomes included postoperative pelvic ischemia, freedom from reintervention, and the overall 10-year survival rate. RESULTS: There was no significant difference in the perioperative mortality rate between the non-IIAE group (0%) and the IIAE group (2.1%), p = 0.500. The intraoperative limb complications did not differ significantly between the BBT limbs (7.5%), the IIAE + EE limbs (3.5%), and the IBD limbs (3.1%) groups, p = 0.349. The incidence of buttock claudication was significantly greater in the bilateral IIAE + EE group compared to the unilateral IIAE + EE and non-IIAE groups (25%, 11%, and 2.5%, p-value < 0.004), and was similar to the incidence of buttock rest pain with skin necrosis (15%, 0%, and 0%, p < 0.001). During the 10-year follow-up, the BBT limbs group had a significantly lower rate of iliac limb reintervention free time than the IIAE + EE limbs and the IBD limbs groups (88.7%, 98.2%, and 93.8%, p = 0.016). There was no significant difference in the overall 10-year survival rate between the non-IIAE and IIAE groups (51.4% vs. 55.9%, p = 0.703). CONCLUSIONS: The early and late mortality rates were similar between the non-IIAE and IIAE groups. Preserving the IIA is recommended to avoid pelvic ischemic complications. Considering the higher rate of reintervention in the BBT group, the IBD strategy may be preferred for AAIA.

The quality and quantity media-cultured mononuclear cell transplantation is safe and effective in ischemic hindlimb mouse model.

Objective: This study was conducted to investigate in vitro proangiogenic and anti-inflammatory phenotypes and functions and the in vivo efficacy and safety of quality and quantity (QQ) media-cultured mononuclear cells (MNCs) compared with standard cultured MNCs from the peripheral blood of patients with chronic limb-threatening ischemia (CLTI) with atherosclerotic risk factors. Methods: Peripheral blood MNCs (PBMNCs) from patients with CLTI were cultured in QQ culture media or standard culture media. Phenotypic analysis of progenitor cells (CD34+CD133+), M2 macrophages (CD206+), and inactivated T regulatory cells (CD4+CD25+CD127+), colony-forming assay, and tube formation assay of QQ media-cultured MNCs (QQMNCs) and PBMNCs, were conducted. Intramuscular transplantation of QQMNCs or PBMNCs was performed in the ischemic hindlimb model. The clinical appearance of ischemic limbs was observed, and blood flow in ischemic limbs was measured using a laser Doppler perfusion imager. Outcomes were compared between the QQMNC and PBMNC groups. Results: Twenty patients with CLTI were included. The mean percentages of CD34+ cells, CD133+ cells, CD34+CD133+ progenitor cells, CD206+ cells, colony-forming cells, and tube formation were significantly higher in the QQMNCs. The mean percentage of CD4+CD25+CD127+ cells was significantly lower in QQMNC. The colony-forming unit count and Dil-acetylated low-density lipoprotein uptake were significantly greater in QQMNCs. The clinical appearance of post-QQMNC-injected limbs was less severe than the appearance of post-PBMNC-injected limbs. Limb perfusion was significantly better in the QQMNCs. Conclusions: Proangiogenic and anti-inflammatory phenotypes of MNCs cultured in QQ culture media were reproducible. Intramuscular QQMNC transplantation was safe and resulted in better reperfusion of ischemic hindlimbs compared with PBMNCs.

Prevalence and predictors of combined >50% iliocaval venous obstruction and superficial venous reflux in chronic venous insufficiency patients with healed or active venous leg ulcer.

OBJECTIVE: The aim of the present study was to investigate the prevalence and predictors of combined >50% iliocaval venous obstruction (ICVO) and superficial venous reflux (SVR) in patients with chronic venous insufficiency (CVI) with a healed (C5) or an active (C6) venous leg ulcer (VLU). METHODS: We conducted a retrospective review of prospectively collected data from patients with CVI with CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class C5 (healed ulcer) or C6 (active ulcer) with SVR who had been treated at our institution from February 2017 to January 2018. The demographic, clinical, and surgical data and duplex ultrasound and computed tomography venography findings were collected. We used OsiriX MD, version 2.9, software (Pixmeo SARL, Bernex, Switzerland) to measure the vein diameter via multiplanar reconstruction. The prevalence of combined >50% ICVO and SVR was evaluated, and univariate and multivariate analyses were performed to identify the independent predictors of >50% ICVO in patients with CVI and SVR. RESULTS: A total of 79 limbs from 67 patients were enrolled. The mean age was 59.82 ± 12.86 years, the mean body mass index was 28.68 ± 6.41 kg/m2, and 41.8% were men. The prevalence of >50% ICVO in the patients with SVR was 31.6%. Univariate analysis showed a history of deep vein thrombosis (DVT) in the affected leg (P = .001), a VLU in the left leg (P = .033), a history of a recurrent VLU (P = .038), and reversed flow in the superficial epigastric vein (P = .004) were significantly associated with >50% ICVO in patients with CVI and SVR. Multivariate analysis revealed a history of DVT in the affected leg (adjusted odds ratio [aOR], 8.31; 95% confidence interval [CI], 2.29-30.19; P = .001), a VLU in the left leg (aOR, 3.95; 95% CI, 1.18-13.19; P = .026), and a history of a recurrent VLU (aOR, 3.08; 95% CI, 1.02-9.32; P = .047) to be independently associated with combined >50% ICVO and SVR in patients with CVI. CONCLUSIONS: The prevalence of combined >50% ICVO and SVR in patients with CVI and CEAP C5 or C6 was 31.6%. The independent predictors of combined >50% ICVO and SVR in those with CVI were a history of DVT in the affected leg, a VLU in the left leg, and recurrent VLUs.

The Geriatric Nutritional Risk Index predicts amputation after infrapopliteal angioplasty in critical limb ischemia patients.

OBJECTIVE: To validate the Critical Limb Ischemia Frailty Index (CLIFI), and to identify independent predictors of 2-year amputation-free survival after infrapopliteal endovascular treatment for chronic limb-threatening ischemia (CLTI) in Thai patients. METHODS: This retrospective study was conducted during the June 2014 to February 2017 study period. CLTI patients treated with infrapopliteal angioplasty were enrolled and analyzed. A patient was defined as CLIFI positive if two or more of the following criteria were present: Geriatric Nutritional Risk Index (GNRI) < 89.8, low skeletal muscle mass index (<6.87 kg/m2 in males, and <5.46 kg/m2 in females), and/or non-ambulatory status. Kaplan-Meier survival analysis was used to assess 2-year amputation-free survival (AFS), and comparisons were performed using log-rank test. Univariate and multivariate Cox proportional hazards models were used to analyze for significant and independent association, respectively, between preoperative characteristics and AFS. RESULTS: A total of 266 patients and 286 limbs were included. Forty (15.0%) patients were CLIFI positive, and 226 (85.0%) patients were CLIFI negative. The 2-year amputation-free survival rate was 90.3% in the CLIFI positive group, and 86.6% in the CLIFI negative group (p = 0.59). Multivariate analysis revealed the GNRI to be an independent risk factor for amputation within two years after infrapopliteal revascularization (adjusted hazard ratio: 4.87, 95% confidence interval: 1.20-19.70; p = 0.02). CONCLUSIONS: The GNRI was found to independently predict 2-year amputation after infrapopliteal angioplasty in Thai CLTI patients; however, the CLIFI was not found to significantly predict 2-year amputation in this patient population.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms.

BACKGROUND: Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood. METHODS: We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival. RESULTS: Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection. CONCLUSIONS: EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Thrombus extension after cyanoacrylate closure of incompetent saphenous veins.

BACKGROUND: Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins. This study aimed to investigate the incidence, the risk factors for, and the management of thrombus extension after cyanoacrylate closure (TEACAC) of incompetent saphenous veins in patients with chronic venous disease. METHODS: This retrospective study included patients aged >18 years who were diagnosed with chronic venous disease with superficial venous reflux in the great saphenous vein, anterior accessory saphenous vein, or small saphenous vein, and who were treated with CAC at Siriraj Hospital (Bangkok, Thailand) during January 2017 to December 2018. RESULTS: A total of 126 saphenous veins of 101 patients were included. TEACAC occurred in 5 of 101 (4.9%) patients, and in 5 of 126 (3.9%) treated saphenous veins. The mean follow-up time was 285±12 days. Based on Kabnick classification of endovenous heat-induced thrombosis (EHIT), the following TEACAC grades were observed: grade I (N.=2), grade II (N.=1), grade III (N.=2), and grade IV (N.=0). No patient or procedural predictive factors for TEACAC were identified. In patients with TEACAC-1 or TEACAC-2, the thrombus spontaneously disappeared by the 2-week follow-up. Patients with TEACAC-3 received therapeutic rivaroxaban or dabigatran, which resolved the thrombus within 2-4 weeks. No deep vein thrombosis or symptomatic pulmonary embolism was found. CONCLUSIONS: TEACAC was found not to be a rare complication after CAC. All patients should be informed of the risk of TEACAC prior to treatment. Treatment of TEACAC class 1-3 following EHIT guideline seems to be both safe and effective.

Novel culture media enhances mononuclear cells from patients with chronic limb-threatening ischemia to increase vasculogenesis and anti-inflammatory effect.

BACKGROUND: Quality and Quantity culture media (QQ culture media) was reported to enhance vasculogenesis and angiogenesis function of mononuclear cells (MNCs) from healthy volunteers. In this study, MNCs from chronic limb-threatening ischemia (CLTI) patients were cultured in QQ culture media, and then investigated for angiogenesis-related phenotype and function. METHODS: Patients aged ≥ 18 years with CLTI caused by atherosclerosis of the lower extremities were prospectively recruited at Siriraj Hospital (Bangkok, Thailand) during July 2017-December 2018. Peripheral blood mononuclear cells (PBMNCs) were isolated from peripheral blood. PBMNCs were cultured in either QQ culture media or standard culture media. The number of CD34+CD133+ cells, CD206+ cells, CD4+CD25+CD127+ cells, colony formation assay, and human umbilical vein endothelial cell (HUVEC) tube formation assay in MNCs were compared between those cultured in QQ culture media and those cultured in standard culture media. RESULTS: Thirty-nine patients were included with a mean age of 69 ± 11 years. Diabetes mellitus was found in 25 (64%) patients. The percentage of CD34+CD133+ progenitor cells in MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 4.91 ± 5.30% and 0.40 ± 0.46%, respectively (p < 0.0001). The percentage of CD206+ cells in MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 19.31 ± 11.42% and 4.40 ± 2.54%, respectively (p < 0.0001). The percentage of inactive population of T regulatory cells (CD4+CD25+CD127+ cells) in MNCs cultured in standard culture media and in MNCs cultured in QQ culture media was 14.5 ± 10.68% and 1.84 ± 1.37%, respectively (p < 0.0001). The total number of colony-forming units from MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 8.86 ± 8.35 of 2 × 105 cells/dish, and 0.58 ± 1.05 of 2 × 105 cells/dish, respectively (p < 0.0001). The mean intensity of Dil-Ac-LDL uptake that incorporated into the HUVEC forming tube was 1.37 ± 0.88 in MNCs cultured in QQ culture media, and 0.78 ± 0.41 in MNCs cultured in standard culture media. (p < 0.0003). CONCLUSIONS: MNCs from CLTI patients that were cultured in QQ culture media had a significantly higher number of CD34+CD133+ cells and anti-inflammatory cells, and higher angiogenesis-related function compared to MNCs cultured in standard culture media.

Cyanoacrylate Granuloma After Cyanoacrylate Closure of Incompetent Saphenous Veins.

BACKGROUND: Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins. OBJECTIVE: To evaluate the incidence, the risk factors for, and the management of cyanoacrylate granuloma (CAG) after CAC of incompetent saphenous veins in patients with chronic venous disease. MATERIALS AND METHODS: Data specific to incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, that were treated with CAC were retrospectively evaluated. RESULTS: A total of 126 saphenous veins from 101 patients were included. Recapture of the delivery catheter before withdrawal was not performed in all patients. Cyanoacrylate granuloma occurred in 3 of 101 (2.9%) patients, and in 3 of 126 (2.3%) treated saphenous veins. All patients with CAG presented with granuloma and abscess at the puncture site 3 to 5 months after CAC. All patients were treated with incision, drainage, and removal of the glue foreign body. No recurrent granuloma was observed during the study period. No patient or procedural predictive factor for CAG was identified. CONCLUSION: Cyanoacrylate granuloma is not a rare complication after CAC when recapture of the delivery catheter is not performed. Patients should be advised of the possibility of CAG after CAC.

Peripheral blood mononuclear cell transplantation to treat no-option critical limb ischaemia: effectiveness and safety.

OBJECTIVE: Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. METHOD: This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5-10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×1010) with CD34+ cells (2.1±1.2×108) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle-brachial index, toe-brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. RESULTS: Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. CONCLUSION: Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.

Hypersensitivity reaction after cyanoacrylate closure of incompetent saphenous veins in patients with chronic venous disease: A retrospective study.

PURPOSE: The objective of this study was to evaluate the incidence of, the risk factors for, the nature of the disease, and the management of hypersensitivity reaction (HSR) after cyanoacrylate closure (CAC) of incompetent saphenous veins in patients with chronic venous disease. METHODS: Data consisting of all incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, treated with CAC at Siriraj Hospital (Bangkok, Thailand) from January 2017 to December 2018 were retrospectively evaluated. RESULTS: A total of 126 saphenous veins, including 106 great saphenous veins (84.1%), 7 anterior accessory saphenous veins (5.6%), and 13 small saphenous veins (10.3%) of 126 limbs from 101 patients were included. A HSR occurred in 16 of 101 patients (15.8%), in 19 of 126 limbs (15.0%), and in 19 of 126 treated saphenous veins (15.0%). HSR-related erythema, itching, swelling, and pain occurred in 100.0%, 95.0%, 68.4%, and 52.6%, of HSR patients, respectively. HSR occurred 1 week after CAC. All HSR symptoms were mild, could be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and antihistamine, and were resolved within 1 week. The risk factors for HSR were suprafascial saphenous vein with a depth <1 cm from the skin, and saphenous vein diameter of ≥8 mm. CONCLUSIONS: A HSR occurred in 15.8% of patients and in 15.0% of limbs after CAC. Risk factors for HSR were a suprafascial saphenous vein located close to the skin and a large saphenous vein. All HSR symptoms were mild in severity, occurred at 1 week after CAC, and were resolved within 1 week after treatment with nonsteroidal anti-inflammatory drugs and antihistamines. To prevent HSR, CAC should be avoided in suprafascial saphenous veins that are located close to the skin, and CAC in saphenous veins with a size of ≥8 mm should be performed with caution.

Early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between severe and non-severe infrarenal neck angulation.

BACKGROUND: Abdominal aortic aneurysm with severe infrarenal neck angle (>60°) has long been thought to be an obstacle to endovascular aneurysm repair. However, some previous studies reported endovascular aneurysm repair to be safe and efficacious for treating abdominal aortic aneurysm in patients with severe neck angulation. The aim of this study was to investigate the early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between patients with severe and non-severe infrarenal neck angulation. METHODS: Fifty-four severe and 144 non-severe neck angulation patients who were treated at Siriraj Hospital (Bangkok, Thailand) during January 2010-October 2013 were recruited. The primary endpoints were intraoperative neck complications (e.g., type 1A endoleak or proximal graft migration) and immediate adjunct aortic neck procedures. The secondary endpoints included perioperative mortality, overall survival, and the proportion of patients that were reintervention-free at five years compared between the severe and non-severe groups. RESULTS: Severe angulation patients were significantly older than non-severe angulation patients (77 ± 6.3 vs. 74 ± 7.9 years; p = 0.021). The median proximal angle was significantly greater in the severe group (82° vs. 13.5°; p < 0.001). Intraoperative proximal neck complications developed in 29.6% of patients in the severe angulation group compared with 9.0% in the non-severe group (p < 0.001). Significantly more patients in the severe group required intraoperative adjunct procedures (29.6% vs. 7.6%; p < 0.001). There was no significant difference in perioperative mortality between groups. At the five-year follow-up, there was no significant difference between groups for overall survival or the proportion of patients that remained reintervention-free. CONCLUSIONS: Endovascular aneurysm repair to treat abdominal aortic aneurysm in patients with severe proximal neck angulation is technically feasible and safe Although the severe angulation group had a higher rate of intraoperative neck complications and immediate adjunct neck procedures than the non-severe group, there was no significant difference between groups for 30-day mortality, overall survival or the proportion of patients who remained reintervention-free at five years.

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.

Factors that influence venous leg ulcer healing and recurrence rate after endovenous radiofrequency ablation of incompetent saphenous vein.

OBJECTIVE: Endovenous radiofrequency ablation (RFA) is one of the most popular techniques for correcting superficial vein reflux. However, the effectiveness of RFA of superficial vein reflux in patients with active or healed venous leg ulcer (VLU) is unknown. Accordingly, the objective of this study was to evaluate the healing rate, the recurrence rate, and the factors significantly associated with healing and recurrence in patients with active or healed VLU who had superficial venous reflux treated with RFA. METHODS: We retrospectively reviewed all healed VLU or active VLU patients treated with RFA at the Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January 2011 to December 2017 to evaluate the rate of VLU healing and recurrence. Time to healing and time to ulcer recurrence were determined by Kaplan-Meier survival analysis. Risk factors were assessed to determine their association with VLU healing and recurrence by Cox regression survival analysis. RESULTS: RFA of the great saphenous vein (n = 56), anterior accessory saphenous vein (n = 5), or both (n = 1) was performed on 62 limbs with active (n = 32) or healed (n = 30) VLUs. The mean age of patients was 65.4 ± 9.8 years, and 80% were female. Deep venous insufficiency was present in 10 limbs (16%). Pathologic perforating vein was found in 17 patients (27%). Concomitant ultrasound-guided foam sclerotherapy (UGFS) of the pathologic perforating vein was performed in 12 limbs (19%). Concomitant phlebectomy was performed in 19 limbs (31%). The median follow-up time was 753 days after RFA. VLU healed in 31% of patients at 3 months, in 56% at 6 months, and in 66% at 1 year after RFA. Concomitant UGFS of the pathologic perforating vein was the only factor significantly associated with VLU healing (hazard ratio, 2.84; 95% confidence interval, 1.07-7.55; P = .037). VLU recurrence was found in 8% of patients at 1 year, in 14% at 2 years, and in 23% at 3 years after RFA. Deep vein reflux was the only identified risk factor for VLU recurrence (hazard ratio, 3.72; 95% confidence interval, 1.05-13.21; P = .042). CONCLUSIONS: UGFS of the pathologic perforating vein at the time of RFA of saphenous vein reflux improved VLU healing. VLU recurrence was more frequent in patients with concomitant deep vein reflux. The authors suggest performing UGFS of the pathologic perforating vein at the time of RFA to improve VLU healing and monitoring of patients with associated deep vein reflux for ulcer recurrence.

Prevalence, risk factors, and evaluation of iliocaval obstruction in advanced chronic venous insufficiency.

OBJECTIVE: The aim of this study was to investigate the prevalence and clinical predictors of >50% iliocaval venous obstruction (ICVO) in Thai patients with lipodermatosclerosis and healed or active venous ulcers and the diagnostic accuracy of duplex ultrasound (DUS) compared with computed tomography venography (CTV). METHODS: Limbs with lipodermatosclerosis, healed venous leg ulceration, or active venous leg ulceration were prospectively evaluated by DUS and CTV. Loss of respiratory variation in the common femoral vein (CFV) and reversed flow in the superficial epigastric vein (SEV) were evaluated by DUS. Percentage of venous obstruction was measured by CTV. The prevalence and clinical predictors of >50% ICVO were determined, and the accuracy of DUS for diagnosis of >50% ICVO was compared with the diagnostic accuracy of CTV. RESULTS: A total of 106 patients (135 limbs) were enrolled. The mean age was 58 ± 12 years, and 57 (54%) patients were female. Previous history of deep venous thrombosis (DVT) in the symptomatic leg was documented in 21 (15.6%) limbs; >50% ICVO by CTV was found in 38 (28.1%) limbs. Independent predictors of >50% ICVO included left leg (P = .001) and previous history of DVT in the affected leg (P = .001). For diagnosis of >50% ICVO, the sensitivity and specificity of loss of respiratory variation in the CFV were 23.7% and 100%, respectively; the sensitivity and specificity of reversed flow in the SEV were 7.9% and 100%, respectively. CONCLUSIONS: Limbs with lipodermatosclerosis or with healed or active venous ulceration, especially in the left limb or in limbs with a history of DVT in the affected limb, had a high prevalence of ICVO; these limbs should be routinely studied with DUS. Limbs with an abnormal finding on DUS, including loss of respiratory variation in the CFV or reversed flow in the SEV, should be routed for venous intervention, and those with normal DUS findings should be referred for CTV.

Outcomes of Open Repair, Fenestrated Stent Grafting, and Chimney Grafting in Juxtarenal Abdominal Aortic Aneurysm: Is It Time for a Randomized Trial?

BACKGROUND: The well-established, gold standard treatment for juxtarenal abdominal aortic aneurysms (JAAAs) is open repair (OR). However, endovascular treatment with fenestrated or chimney grafts has been increasingly performed in the past decade. This study compared the outcomes of OR with 2 endovascular methods in JAAA. METHODS: We retrospectively reviewed consecutive patients with JAAA who underwent OR (n = 32), repair with fenestrated stent grafts (fenestrated endovascular aortic aneurysm repair [FEVAR], n = 20), or chimney grafts (Ch-EVAR, n = 23) during the period from January 2011 to December 2016 at a single center. Our primary end point was perioperative mortality. Secondary end points included renal function impairment, new-onset dialysis, procedural details, and postoperative complications. Kaplan-Meier analysis was used to estimate freedom from late reintervention, primary patency of target vessel stent grafts, and overall survival. RESULTS: There were no significant differences between groups in baseline characteristics. Perioperative mortality was similar in all the 3 groups (3.1% (1/32) in the OR group, 0% in the FEVAR group, and 4.3% (1/23) in the Ch-EVAR group. Mean follow-up duration was 36.7 months (range 1-75 months). There were no significant differences between groups regarding any of the secondary end points, except for blood loss (which was significantly greatest in the OR group), and there was no significant difference in overall survival. Estimated target vessel stent patency at 1 and 4 years was 93.8% and 93.8% in the FEVAR group, and 89.5% and 89.5% in the Ch-EVAR group. There was no significant difference between groups in estimated freedom from late reintervention (96.4% in the OR group, 77.2% in the FEVAR group, and 82.3% in the Ch-EVAR group). CONCLUSIONS: Open surgery is an acceptable and effective treatment for JAAA. However, FEVAR and Ch-EVAR also showed high technical success rates and low perioperative mortality, with acceptable reintervention rates during follow-up.

Incidence, Risk Factors, Progression, and Treatment of Endovenous Heat-Induced Thrombosis Class 2 or Greater After Endovenous Radiofrequency Ablation.

BACKGROUND: Endovenous heat-induced thrombosis (EHIT) is a thrombus that extends from an ablated saphenous vein into the common femoral vein after endovenous radiofrequency ablation (RFA). OBJECTIVE: To investigate the incidence, progression, treatment, and risk factors associated with EHIT-2 or greater after RFA. MATERIALS AND METHODS: This retrospective study included patients diagnosed with symptomatic superficial venous incompetence that were treated by RFA of the great saphenous vein or anterior accessory saphenous vein during the July 2012 to December 2016 study period. Duplex ultrasound scanning was performed at 1 week, 1 month, 3 months, and every year after RFA to detect EHIT. RESULTS: A total of 317 legs from 274 patients were included. The incidence of EHIT-2 or greater was 7.0%, including 5.4% EHIT-2, 1.3% EHIT-3, and 0.3% EHIT-4. No symptomatic pulmonary embolism was found. The independent risk factors for EHIT-2 or greater were vein diameter (p = .027) and concomitant sclerotherapy (p = .037). CONCLUSION: The risk factors found to be independently associated with EHIT-2 or greater were large vein size and concomitant sclerotherapy. Screening for EHIT should be performed in patients with one or both of these risk factors within 1 week after RFA and in patients with postoperative symptoms suggestive of venous thromboembolism.

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.

Customizing elastic pressure bandages for reuse to a predetermined, sub-bandage pressure: A randomized controlled trial.

Objective A randomized clinical trial was performed to compare the effectiveness of unmarked bandages and customized bandages with visual markers in reproducing the desired sub-bandage pressure during self-bandaging by patients. Method Ninety patients were randomly allocated to two groups ("customized bandages" and "unmarked bandages") and asked to perform self-bandaging three times. The achievement of a pressure between 35 and 45 mmHg in at least two of the three attempts was defined as adequate quality. Results Adequate quality was achieved by 33.0% when applying the unmarked bandages, and 60.0% when applying the customized bandages ( p = 0.02). Use of the customized bandage and previous experience of bandaging were independent predictors for the achievement of the predetermined sub-bandage pressure ( p = 0.005 and p = 0.021, respectively). Conclusion Customized bandages may achieve predetermined sub-bandage pressures more closely than standard, unmarked, compression bandages. Clinical trials registration ClinicalTrials.gov (NCT02729688). Effectiveness of a Pressure Indicator Guided and a Conventional Bandaging in Treatment of Venous Leg Ulcer. https://clinicaltrials.gov/ct2/show/NCT02729688.

A new pretest probability score for diagnosis of lower limb deep vein thrombosis in unselected population of outpatients and inpatients.

Objective To develop a new pretest probability score for deep vein thrombosis (DVT) in unselected population of outpatients and inpatients. Methods The new score was developed using independent factors from 500 patients clinically suspected of leg DVT. The new score was validated in a second group of 315 patients. Results The score consists of four components: unilateral leg pain, confinement to bed, calf enlargement >3 cm compared with the other side, and previous venous thromboembolism. A score ≥2 indicated a high probability while a score <2 indicated low probability. The sensitivity and specificity of the new score were 71.60% and 79.49%, respectively. The area under the receiver operating characteristic curve for the new score was 0.79. The combination of a new score <2 and D-dimer level <500 µg/L had a negative predictive value of 96.43%. Conclusions Our new score was valid in an unselected population of outpatients and inpatients.