Vein Patch Closure Using Below the Knee Greater Saphenous Vein for Femoral Endarterectomy Procedures is Not Always a Safe Choice.

BACKGROUND: The complication of vein patch rupture is well described after carotid patch angioplasty; however, there is a paucity of data about the safety of vein patch closure in the setting of femoral endarterectomy. METHODS/RESULTS: From May 2012 to May 2015, 115 femoral endarterectomies with patch closure were performed. A patch rupture occurred in three cases (2.6%) with a mortality rate of 66% (2/3). In all cases the greater saphenous vein below the knee was used as patch material. DISCUSSION/CONCLUSION: Vein patches, particularly from small calibre veins, should be excluded in femoral endarterectomy procedures as they pose a substantial risk of rupture.

Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years.

BACKGROUND: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. METHODS: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. RESULTS: A total of 83,253 patients were included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. CONCLUSIONS: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.

Editor's Choice: Contemporary treatment of popliteal artery aneurysm in eight countries: A Report from the Vascunet collaboration of registries.

OBJECTIVES: To study contemporary popliteal artery aneurysm (PA) repair. METHODS: Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland). RESULTS: From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers. Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%. Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture. CONCLUSIONS: Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted.

International variations in infrainguinal bypass surgery - a VASCUNET report.

OBJECTIVES: To compare practice in lower limb bypass surgery in nine countries. DESIGN: A prospective study amalgamating and analysing data from national and regional vascular registries. METHODS: A table of data fields and definitions was agreed by all member countries of the Vascunet Collaboration. Data from January 2005 to December 2009 was submitted to a central database. RESULTS: 32,084 cases of infrainguinal bypass (IIB) in nine countries were analysed. Procedures per 100,000 population varied between 2.3 in the UK and 24.6 in Finland. The proportion of women varied from 25% to 43.5%. The median age for all countries was 70 for men and 76 for women. Hungary treated the youngest patients. IIB was performed for claudication for between 15.7% and 40.8% of all procedures. Vein grafts were used in patients operated on for claudication (52.9%), for rest pain (66.7%) and tissue loss (74.1%). Italy had the highest use of synthetic grafts. Among claudicants 45% of bypasses were performed to the below knee popliteal artery or more distally. Graft patency at 30 days varied between 86% and 99%. CONCLUSIONS: Significant variations in practice between countries were demonstrated. These results should be interpreted alongside the known limitations of such registry data with respect to quality and completeness of the data. Variation in data completeness and data validation between countries needs to be improved for useful international comparison of outcomes.

Variation in clinical practice in carotid surgery in nine countries 2005-2010. Lessons from VASCUNET and recommendations for the future of national clinical audit.

OBJECTIVES: The aim of the study was to analyse variation in carotid surgical practice, results and effectiveness in nine countries. PATIENTS AND METHODS: A total of 48,185 carotid endarterectomies (CEAs) and 4602 carotid artery stenting (CAS) procedures were included in the comparison. A theoretical effectiveness of CEA provision for each country was estimated. RESULTS: 92.6% of the CEAs were performed according to the inclusion criteria based on the current European recommendations and had a theoretical benefit for the patient. The indication for surgery was symptomatic stenosis in 60.1% and this proportion varied between 31.4% in Italy and 100% in Denmark. The overall combined stroke and death rate in symptomatic patients was 2.3%. This varied between rates of 0.9% in Italy and 3.8% in Norway. The overall combined stroke and death rate in asymptomatic patients was 0.9%. It was lowest in Italy at 0.5%, and highest in Sweden at 2.7%. We estimated that the stroke prevention rate per 1000 CEAs varied from 72.9 in Italy to 130.8 in Denmark. CONCLUSIONS: There is significant variation in clinical practice across the participating countries. The theoretical stroke prevention potential of CEA seems to vary between participating countries due to differences in the inclusion criteria.

Treatment of abdominal aortic aneurysm in nine countries 2005-2009: a vascunet report.

OBJECTIVES: To study contemporary treatment and outcome of abdominal aortic aneurysm (AAA) repair in nine countries. DESIGN AND METHODS: Data on primary AAA repairs 2005-2009 were amalgamated from national and regional vascular registries in Australia, Denmark, Finland, Hungary, Italy, Norway, Sweden, Switzerland and the UK. Primary outcome was in-hospital or 30-day mortality. Multivariate logistic regression was used to assess case-mix. RESULTS: 31,427 intact AAA repairs were identified, mean age 72.6 years (95% CI 72.5-72.7). The rate of octogenarians and use of endovascular repair (EVAR) increased over time (p < 0.001). EVAR varied between countries from 14.7% (Finland) to 56.0% (Australia). Overall perioperative mortality after intact AAA repair was 2.8% (2.6-3.0) and was stable over time. The perioperative mortality rate varied from 1.6% (1.3-1.8) in Italy to 4.1% (2.4-7.0) in Finland. Increasing age, open repair and presence of comorbidities were associated with outcome. 7040 ruptured AAA repairs were identified, mean age 73.8 (73.6-74.0). The overall perioperative mortality was 31.6% (30.6-32.8), and decreased over time (p = 0.004). CONCLUSIONS: The rate of AAA repair in octogenarians as well as EVAR increased over time. Perioperative outcome after intact AAA repair was stable over time, but improved after ruptured repair. Geographical differences in treatment of AAA remain.

[Inferior vena cava thrombosis after laparoscopy]. / Thrombose der Vena cava Inferior nach Diagnostischer Laparoskopie.

HISTORY AND FINDINGS: A previously healthy 43-year-old woman was admitted because of pain in the lower abdomen. Abdominal and transvaginal ultrasound revealed a cystic structure in the right ovary, providing the indication for an exploratory laparoscopy. A hemorrhagic corpus luteum was enucleated. Laboratory tests had merely shown a raised C-reactive protein level and marginally elevated leukocytes. A family history of thrombotic episodes had been elicited. FURTHER COURSE, DIAGNOSIS AND TREATMENT: Although heparin had been applied increasing swelling developed in both thighs and lower legs at day six, indicating thrombosis of the inferior vena cava. Laboratory tests revealed a mutation in factor V (Leiden). Computed tomography showed complete thrombotic IVC occlusion. Thrombolytic treatment with recombinant tissue plasminogen was initiated, direct thrombus aspiration attempted and a filter inserted in the IVC. Low molecular heparin was infused, replaced by oral anticoagulation with phenprocoumon. Subsequent Doppler ultrasound examination demonstrated almost complete resolution of the thrombus, except for a few small residual thrombi. CONCLUSION: This case demonstrates that even minor laparoscopic interventions carry the risk of an IVC thrombosis as a late complication, indicating appropriate measures to prevent thrombosis.

Outcome following carotid endarterectomy: lessons learned from a large international vascular registry.

OBJECTIVES: The aim of the study was to assess if technical and patient-related factors are related to outcome after carotid surgery. DESIGN: Vascunet is a collaboration of national and regional registries with 10 contributing countries. PATIENTS AND METHODS: Data from 48,035 carotid endarterectomies (CEAs) performed in 383 centres, during 2003-2007, were merged into a common database. RESULTS: CEA was performed without patch (34%), with patch (40%) or with eversion (26%) in 74% for symptomatic and in 26% for asymptomatic disease. Overall (in-hospital and 30-day) mortality was 0.45%. Type of CEA or anaesthesia did not affect mortality, nor did contralateral occlusion. Mortality was higher in patients above the age of 75 years, for both genders (p < 0.05). The overall (in-hospital) stroke rate was 1.9%, the method of anaesthesia did not affect stroke rate. It was higher in patients with contralateral occlusion (4.6% vs. 2.5%, p = 0.002). Standard CEA without patch had a higher stroke rate than when a patch was used (2.3 vs. 1.7%, p = 0.015). Female patients >75 years had a higher stroke rate than younger women (2.0% vs. 1.6%, p = 0.078); this difference was not observed in men. CONCLUSIONS: Although there are limitations with registry data, the large number of cases involved provides useful information on outcomes, supplementing data from the randomised clinical trials (RCTs).

Subduction and collision processes in the Central Andes constrained by converted seismic phases.

The Central Andes are the Earth's highest mountain belt formed by ocean-continent collision. Most of this uplift is thought to have occurred in the past 20 Myr, owing mainly to thickening of the continental crust, dominated by tectonic shortening. Here we use P-to-S (compressional-to-shear) converted teleseismic waves observed on several temporary networks in the Central Andes to image the deep structure associated with these tectonic processes. We find that the Moho (the Mohorovicic discontinuity--generally thought to separate crust from mantle) ranges from a depth of 75 km under the Altiplano plateau to 50 km beneath the 4-km-high Puna plateau. This relatively thin crust below such a high-elevation region indicates that thinning of the lithospheric mantle may have contributed to the uplift of the Puna plateau. We have also imaged the subducted crust of the Nazca oceanic plate down to 120 km depth, where it becomes invisible to converted teleseismic waves, probably owing to completion of the gabbro-eclogite transformation; this is direct evidence for the presence of kinetically delayed metamorphic reactions in subducting plates. Most of the intermediate-depth seismicity in the subducting plate stops at 120 km depth as well, suggesting a relation with this transformation. We see an intracrustal low-velocity zone, 10-20 km thick, below the entire Altiplano and Puna plateaux, which we interpret as a zone of continuing metamorphism and partial melting that decouples upper-crustal imbrication from lower-crustal thickening.

[Surgical therapy of primary varicose veins]. / Die chirurgische Therapie der primären Varikose.

The principle of varicose vein surgery still remains the interruption of all insufficient communications between the deep and the superficial venous system and removal of the varicosities. The basis for differentiated surgical treatment is accurate preoperative assessment. Careful dissection of the saphenofemoral junction through a suprainguinal incision, with division of all the branches and flush tie of the long saphenous vein combined with invaginated stripping of the long saphenous vein to just below the knee, appears to be the method of choice for good clinical results and a low incidence of damage to the saphenous nerve. Oesch recently introduced a new technique of perforate invaginate (PIN) stripping which gives even better cosmetic results. Regarding the short saphenous vein, preoperative localization of the exact level of the saphenopopliteal junction is of major importance in the prevention of recurrence. Simple evulsion or epifascial or subfascial ligation were the most common treatments for incompetent perforating veins for many years. In 1985 Hauer described endoscopic subfascial dissection of perforating veins (ESDP), which reduces delayed wound healing, especially in trophic skin changes. Deprivation of blood supply with a pneumatic tourniquet such as the Löfqvist roller cuff is necessary. The tributaries are removed by stab evulsion phlebectomy with specially designed hooks. This technique was originally introduced by Muller for ambulatory treatment of varicose veins. The incisions of 1-3 mm guarantee excellent cosmesis and minimal trauma. Adhesive tape is used to close the incisions. A number of alternative techniques such as cryosurgery, laser surgery, paratibial fasciotomy and the CHIVA technique (Conservative Treatment and Haemodynamics in Venous Insufficiency in Outpatient Departments) are briefly described. Complications of varicose vein surgery are rare. Minor complications are skin nerve injuries, haematomas, infections and lymphatic fistulas. Major complications such as injuries to the femoral vein or artery occur in less than 0.05%. But once it has occurred it is of paramount importance to recognize the injury at the time of initial surgery, to avoid limb loss. Provided the preoperative assessment is accurate and the principles of selective surgical treatment are followed, the surgeon is able to perform a curative operation with a low complication rate and excellent cosmetic results.

Treatment of pelvic venous spur (May-Thurner syndrome) with self-expanding metallic endoprostheses.

PURPOSE: The application of self-expanding metallic endoprostheses (stents) to treat symptomatic pelvic venous spurs as an alternative to surgery. METHODS: Wallstents with a diameter from 14 to 16 mm and one Cragg stent were placed in the left common iliac vein of eight patients (seven women, one man; mean age 42 years) with a symptomatic pelvic venous spur (left deep venous thrombosis or post-thrombotic leg swelling). Four patients had surgical thrombectomy prior to stent placement. RESULTS: Technical success with immediate reduction of left leg circumference was achieved in all eight patients. A primary patency rate of 100% was observed during an average follow-up of 3 years (range 10-121 months). There were no procedural or stent-related complications. CONCLUSION: The percutaneous transfemoral placement of self-expanding metallic stents is an effective minimally invasive alternative to surgery in the treatment of symptomatic pelvic venous spur.

Long-term results after open and semiclosed thrombendarterectomy for aortoiliac occlusive disease.

OBJECTIVES: This study reviews the long-term results of 514 aortoiliac thrombendarterectomies (TEA's). DESIGN: A prospective study in a major university hospital in Switzerland. SUBJECTS: 353 male and 62 female patients with aortoiliac occlusive disease. Operative indications: disabling claudication (n=334), rest pain (n=44), and gangrene (n=37). METHODS: Open and semiclosed TEA's were performed on 167 and 347 limbs, respectively. Follow-up was continuous and complete in 97.1 % of patients over a period of more than 15 years. RESULTS: The overall life-table patency rate at 5, 10, and 15 years postoperatively were 93.4 %, 90.4 %, and 84.2 %, respectively. Fifteen years postoperatively, the patency rate of 92.3 % after open TEA was significantly higher (p<0.04) than after semiclosed TEA (79.5 %). However, similar patency rates of 69.5 % and 69.8 % were observed 20 years postoperatively. Further significant prognostic factors on patency were: anatomic localization (p<0.004), preoperative stage of arterial occlusive disease (p<0.008), and gender (p<0.007). Patient's age did not influence the outcome in terms of patency. Hospital mortality rate was 1.2 %. Early obstruction occurred in 2.2 %, leading to subsequent early amputation of 1.4 % and reoperations in 1.2 %. The long-term actuarial survival rates of the patients were 55 %, 36 %, and 18 % after 10, 15, and 20 years postoperatively. CONCLUSION: Both open and semiclosed TEA give highly satisfactory long term results in aortoiliac occlusive disease with a low morbidity and low mortality.

Angioscopy guided in situ bypass versus angioscopy guided non reversed bypass for infrainguinal arterial reconstructions. A comparison of outcome.

In situ bypass grafting depends on an adequate ipsilateral greater saphenous vein. To profit from a tapered, valveless conduit in legs without an adequate greater saphenous vein, we routinely used the contralateral saphenous vein non reversed. In some reconstructions to the infrageniculate popliteal and the proximal anterior tibial artery we used the non reversed instead of the in situ technique because of the distance between the natural course of the saphenous vein and the recipient artery. This retrospective study compares the outcome of 48 in situ bypasses to the outcome of 66 non reversed bypasses. Endoluminal manipulations in all veins were visually controlled using an angioscope. The two groups of bypasses (in situ versus non reversed) did not differ concerning age, sex, risk factors, operative mortality, indication for surgery and distribution of the recipient arteries. There was a tendency for a lower wound complication rate in "in situ" compared to non reversed bypasses (10% versus 27%; p = 0.086). There were no differences in cumulative primary and primary assisted patency rates between the two groups after two years. We prefer the angioscopy guided in situ technique for reconstructions to infrageniculate arteries because of a low wound complication rate and excellent patency rates. In the absence of an adequate ipsilateral saphenous vein and in reconstructions to recipient arteries not presenting themselves for the in situ technique, similar results can be achieved with angioscopically prepared non reversed grafts.

[Cost saving after-care in infra-inguinal vascular reconstruction]. / Kostensparende Nachkontrollen nach infrainguinalen Gefässrekonstruktionen.

To assess the indications for routine colour flow duplex surveillance, 43 infrainguinal autogenous vein grafts were prospectively entered into a surveillance protocol. Screening consisted of measurements of ankle brachial indices (ABI) and colour flow duplex imaging of the entire graft length. All grafts at risk had a serial fall in resting ABI of more than 0.1. This study suggests that resting ABI measurements are a very sensitive and non-expensive primary screening procedure, provided that all grafts with ABI changes of more than 0.1 are further evaluated. About 60% of ABI-screened grafts needed further evaluation because of ABI changes of greater than 0.1, incompressibility of arteries or extension of the graft to the ankle or pedal arteries. Colour flow duplex scanning was very useful in excluding of identifying and localising graft problems and deciding on further invasive diagnostic and therapeutic procedures.

[Abdominal aortic aneurysm. Risks and early postoperative course]. / Das Bauchaortenaneurysma. Risiken und frühpostoperativer Verlauf.

A review of the literature shows a very variable mortality, especially after emergency operations for abdominal aortic aneurysm (AAA) (14-70%). We therefore analyzed the mortality of our patients in different subgroups. The hospital data of 82 patients operated on for abdominal aortic aneurysm were analyzed retrospectively. 42 patients underwent emergency operations and 40 patients elective surgery. The mean age was 67.5 +/- 9.4 and 70.7 +/- 7.3 years respectively. The overall 30-day mortality in elective cases was 5% (2/40); elective patients under the age of 75 years had a mortality of 0%. 33% of the emergency cases died within 30 days. The mortality in various subgroups was as follows: "asymptomatic AAA" 5.4% (2/37), "symptomatic AAA" 10% (1/10), "retroperitoneal rupture" 34% (11/32) and "intraperitoneal rupture" 66.6% (2/3). Preoperatively 21/42 patients who underwent emergency surgery were in hypovolemic shock (systolic blood pressure < or = 90 mm Hg). The mortality of these patients was 52% (11/21) compared to 9.5% (2/21), (p < 0.01), in emergency patients without preoperative shock. The causes of death after emergency procedures were hypovolemic shock in 6, heart failure in 4, and multi-organ failure, respiratory insufficiency, unknown and pulmonary embolism in 1 each. 5/14 patients died in theatre. Two patients died after elective procedures: one 9 days postoperatively from myocardial infarction and the second 23 days after the operation from an unknown cause. Reoperation rate after elective and emergency procedures was 7.5% and 16.6% respectively. Mortality after reoperation was 40%.(ABSTRACT TRUNCATED AT 250 WORDS)