Predictors of 1-Year Survival After Endovascular Aneurysm Repair.

OBJECTIVE/BACKGROUND: The purpose of this study was to determine the preoperative variables that best predict 1-year survival following elective endovascular aneurysm repair (EVAR), a period of time that would suggest the patient had benefited from the procedure. Most EVAR survival studies focus on early and late survival; scant information is available for 1-year survival. METHODS: Data from two Australian audits of EVAR (1999-2001 and 2009-13) were combined (n = 1,647). Preoperative variables included routine demographic data, clinical health assessments, computed tomography-derived anatomical data, and all-cause mortality. Univariate and multivariate logistic regressions determined which variables best predicted 1-year survival. RESULTS: One-year survival after EVAR was 93.7% (1,544/1,647) and 30-day survival was 98.4% (1,620/1,647). Univariate analyses found that nine preoperative variables were significantly associated with 1-year survival. Five variables were included in the final multivariate model: American Society of Anesthesiologists physical status, aneurysm diameter, creatinine, respiratory assessment, and severity of iliac artery calcification (receiver-operator curve 0.717, R(2) = .117). Predicted 1-year survival ranged from 98.6% to 68.0%, based on differences in aneurysm size and patient comorbidities. CONCLUSION: Personalised 1-year survival risk enables surgeons and patients to consider seriously the risks and benefits of EVAR prior to surgery.

Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review.

Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥ 45 mmHg) and transcutaneous pressure of oxygen (TcPO2 ) ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ankle brachial index (ABI) < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation.

Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review.

Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus are important to estimate the risk of amputation, ulceration, wound healing and the presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another and to evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction angiography and colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies instrument. Of the 6629 studies identified, ten met the criteria for inclusion. In these studies, the patients had a median age of 60-74 years and a median duration of diabetes of 9-24 years. Two studies reported exclusively on patients with symptomatic (ulcerated/infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio and negative likelihood ratio (NLR) of an ABI threshold <0.9 ranged from 2 to 25 (median 8) and <0.1 to 0.7 (median 0.3), respectively. In patients with neuropathy, the NLR of the ABI was generally higher (two out of three studies), indicating poorer performance, and ranged between 0.3 and 0.5. A toe brachial index <0.75 was associated with a median positive likelihood ratio and NLRs of 3 and ≤ 0.1, respectively, and was less affected by neuropathy in one study. Also, in two separate studies, pulse oximetry used to measure the oxygen saturation of peripheral blood and Doppler wave form analyses had NLRs of 0.2 and <0.1. The reported performance of ABI for the diagnosis of PAD in patients with diabetes mellitus is variable and is adversely affected by the presence of neuropathy. Limited evidence suggests that toe brachial index, pulse oximetry and wave form analysis may be superior to ABI for diagnosing PAD in patients with neuropathy with and without foot ulcers. There were insufficient data to support the adoption of one particular diagnostic modality over another and no comparisons existed with clinical examination. The quality of studies evaluating diagnostic techniques for the detection of PAD in individuals with diabetes is poor. Improved compliance with guidelines for methodological quality is needed in future studies.

Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review.

Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

Development of an automated measure of iliac artery tortuosity that successfully predicts early graft-related complications associated with endovascular aneurysm repair.

OBJECTIVES: Iliac artery tortuosity has been linked to the likelihood of complications following endovascular aneurysm repair (EVAR). Measures of tortuosity can be established from CT images; however, the reproducibility of existing scoring techniques has not been clearly established. It remains unclear whether it is tortuosity at focal locations or for the vessel as a whole that is most relevant to adverse events. The two aims of this study were to develop an automated measure of iliac artery tortuosity to assist with surgical planning by providing an objective assessment of procedural difficulty, and to correlate this measure with early postoperative outcomes. DESIGN AND METHODS: Unlike existing approaches, the present measure of tortuosity considers spatial scale, which incorporates the effects of local anatomy. A computerized imaging algorithm was used to segment vasculature and establish a medial line and vascular boundary from contrast enhanced CT scans of 150 patients undergoing EVAR. Two tortuosity measures were examined: curvature and vessel to straight-line length (L1/L2-ratio). For a given spatial scale, the maximum tortuosity was computed on both iliac arteries and the artery with the lower maximum was selected for analysis. Correlation of tortuosity with early (<30 day) and longer-term graft-related complications was assessed. RESULTS: Maximal tortuosity at a 10 mm scale was a significant predictor of early (<30 day) complications (p = .016 for curvature and p = .006 for L1/L2-ratio), but not of long-term complications. Aneurysmal diameter was independent of tortuosity (Pearson's r value = -.006). CONCLUSION: The results demonstrate that, at a local scale, tortuosity measures are correlated with early outcomes. The spatial scale at which tortuosity is measured is important. The optimal scale of 10 mm implies that adverse events could be linked to a focal anatomical location.

Venous ulceration contaminated by multi-resistant organisms: larval therapy and debridement.

A 72-year-old female with venous insufficiency presented to a hospital-based multidisciplinary wound clinic after 20 years of recurrent episodes of venous leg ulcers. Examination showed bilateral leg ulcers with no evidence of arterial insufficiency, but complicated by considerable devitalised tissue, abnormally high bacterial load and the presence of multi-resistant organisms. The ulcers were initially treated with larvae to aid debridement and reduce the bacterial load, prior to skin grafting. Although ulcer free for a period of 4 months, further debridement was required when the skin condition deteriorated. Surgical intervention was chosen as the preferred method by the surgeons for a second acute care admission using hydrosugery, along with supplementary skin grafts and compression. Ongoing management, consisting of regular debridement, skin care and compression therapy, continues.

Worldwide experience with the Endurant Stent graft: review of the literature.

The Endurant Stent-graft System (Medtronic Vascular, Santa Rosa, CA) is a next-generation device intended to expand the applicability of endovascular aortic repair (EVAR). To date, the Endurant has been evaluated in 9 short- and intermediate-term studies, several in patients presenting with challenging aneurysm anatomies. Consistently, the device in these studies has been shown to be safe and effective, with an excellent rate of deployment success and with very low rates of type I/III endoleaks and reinterventions. Single center experience with Endurant in challenging anatomies with short kinked necks and calcified angulated iliac arteries in patients unfit for open repair and challenging anatomies show promising early results with no difference in mortality, morbidity and reintervention rates, but need cautious application for EVAR outside of the device-specific IFU. The Endurant Stent-graft Natural Selection Global Postmarket Registry (ENGAGE) is a long-term 1266-patient 80-site worldwide prospective postmarket study initiated to augment the knowledge base (poolable and comparable) about EVAR in a real-world population implanted with the Endurant. Technical and clinical data for ENGAGE patients will be reported through the expected completion of 5-year follow-up for all ENGAGE registry patients in 2018. We discuss the evolving challenges for EVAR that the Endurant and other next-generation stent-grafts are designed to address and review outcomes published with the Endurant since the CE marking of the device in July 2008.

Personalised predictions of endovascular aneurysm repair success rates: validating the ERA model with UK Vascular Institute data.

OBJECTIVE: The objective of this study was to externally validate the existing Australian Endovascular aneurysm repair Risk Assessment (ERA) Model using data from a major vascular centre in the United Kingdom. METHODS: Data collected from 312 endovascular abdominal aortic aneurysm repair patients at St George's Vascular Institute, London, UK were fitted to the ERA Model. RESULTS: Despite St George's patients being sicker (p < 0.001), having larger aneurysms (p < 0.001) and being more likely to die (p < 0.05) than the Australian patients, their data fitted the ERA Model well for the risk factors early death, aneurysm-related death, three-year survival and type I endoleaks as evidenced by higher area under ROC curves and/or higher R(2) goodness of fit statistics than the Australian data. CONCLUSIONS: The first external validation of the ERA Model using data from St George's Vascular Institute suggests that this tool can be used in different countries and hospital settings. The authors believe the ERA Model is robust and allows valid personalised predictions of outcomes by surgeons treating routine aneurysms as well as those in tertiary referral practices with more adverse outcomes.

Rationale and design of the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE): interim analysis at 30 days of the first 180 patients enrolled.

AIM: The Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) is a long-term 1200-patient multicenter prospective study initiated to augment the knowledge base (poolable and comparable) about endovascular aortic repair (EVAR) in a real-world population implanted with a single latest-generation stent graft system (Endurant). With enrollment ongoing at 80 high-volume sites, the registry has limited inclusion/exclusion criteria or procedural specification. Technical and clinical data will be reported through 5 years. METHODS: An interim analysis was performed on investigator-reported data for the first 180 patients enrolled. These patients were asymptomatic elderly males (92.1%) with considerable comorbidities. For 47.3% of the patients, the American Society of Anesthesiologists risk class was either III or IV. The Endurant stent graft was successfully deployed in 99.4% of patients for elective treatment of abdominal aortic aneurysm. RESULTS: Through 30 days, the rate of all-cause mortality was 1.7% (N=3), with all 3 deaths classified as procedure-related but not device-related. The rate of secondary endovascular procedures was 1.1%, and the rate of conversion to open repair was 0.6%. At postprocedure and at 30-day follow-up, there were no type I or type III endoleaks and no instances of stent graft kinking, thrombosis, or occlusion. ENGAGE represents the largest real-world registry for any single EVAR stent graft. CONCLUSION: The interim results through 30 days of the first 180 patients enrolled are promising. Longer-term follow-up for more patients will be reported.

Should we develop a core international curriculum for Vascular and Endovascular Surgery?

Vascular and endovascular surgery has undergone a period of extraordinary change during the last 20 years. This is in part due to changes in patient profiles, the development of new, potent drugs and the technological advances in imaging and interventional products. These changes have effectively resulted in the development of an independent specialty, which has needed to define the competencies required for specialist recognition and credentialing. This paper discusses the key aspects of contemporary training in Vascular and Endovascular Surgery, and raises the possibility of developing an agreed core international curriculum.

Simvastatin plus nitric oxide synthase inhibition modulates remote organ damage following skeletal muscle ischemia-reperfusion injury.

UNLABELLED: Ischemia-reperfusion injury (IRI) to the lower extremities causes both local damage and serious dysfunction to remote organs, including lungs and kidneys. However, effective therapies are not available. This study aims to determine if simvastatin reduced the severity of remote damage following IRI. METHODS: Rats were given simvastatin before hind limb IRI. Lung and kidney tissues were assessed for neutrophil infiltration using myeloperoxidase assays and basement membrane damage by quantitative immunohistochemical measurement of collagen IV. The effect of nitric oxide synthase (NOS) inhibition on remote damage after IRI and simvastatin was assessed using the NOS inhibitor, L-NIO. RESULTS: Simvastatin (2 mg/kg) protected kidneys against IRI-induced neutrophil infiltration. Simvastatin also inhibited the IRI-induced activation of MMP-9 in the lungs. However, paradoxically, simvastatin exacerbated IRI-induced neutrophil infiltration into the lungs. IRI induced collagen IV degradation in the lungs but not in the kidneys. The degree of collagen breakdown in the lungs was significantly ameliorated by 2 mg/kg simvastatin. NOS inhibition markedly protected both the lungs and the kidneys against IRI-induced neutrophil infiltration but did not alter collagen IV degradation. Administration of simvastatin to L-Nio-treated animals enhanced the degree of protection against IRI-induced neutrophil infiltration in the kidneys but not in the lungs. CONCLUSIONS: Simvastatin protects against remote IRI-induced damage in the lungs and kidneys, suggesting statins may reduce the severity of IRI during major vascular surgery.

A model to predict outcomes for endovascular aneurysm repair using preoperative variables.

PURPOSE: Models have been developed to predict the likely outcomes of endovascular aneurysm repair (EVAR) for patients, based on a longitudinal Australian audit. METHODOLOGY: Mid-term progress of 961 Australian patients who underwent EVAR has been collected and used to develop predictive models for 17 outcomes. Stepwise forward logistic regressions determined the significant preoperative patient variables to be included in each outcome model. An interactive program was subsequently developed to allow surgeons to review the predicted success rates for patients about to undergo the procedure. Each model was assessed using a global goodness of fit test and was internally validated using bootstrapping. RESULTS: Eight pre-operative variables were included in the interactive model for 17 outcomes. The eight variables used were aneurysm size, age, ASA, gender, creatinine, aortic neck angle, infrarenal neck diameter and infrarenal neck length. The outcomes predicted included perioperative mortality, perioperative morbidity, mid-term survival and reintervention rates. All outcome models achieved reasonable goodness of fit, with the exception of the model for conversion to open repair (p=0.04). With respect to validation, survival, aneurysm related deaths, migrations, ruptures and conversions to open repair performed best in terms of predictive discrimination. Models for survival, migrations and conversions to open repairs performed best in terms of bias corrected R-squared index. The models with the smallest calibration error were 3 and 5 year survival, early deaths and mid-term type I endoleaks. CONCLUSIONS: An interactive model is available, which can assist vascular surgeons to evaluate the expected outcomes for a particular patient undergoing EVAR. The validated model is useful for counselling and pre-operative decision making.

Factors affecting survival after endovascular aneurysm repair: results from a population based audit.

OBJECTIVES: To determine the effect of pre-operative factors on mid-term survival of patients enrolled in an Australian audit of endovascular aneurysm repair (EVAR). DESIGN: Prospective longitudinal national register (audit) of patients undergoing EVAR. METHODS: 961 individuals who had elective or semi-urgent EVAR of abdominal aortic aneurysms were enrolled in the audit between November 1999 and May 2001. Data was contributed by 81 surgeons from 64 hospitals. Kaplan-Meier survival analysis was used to determine survival rates and factors significantly influencing survival. Parametric survival analysis with log-exponential distribution was used to estimate expected 3 and 5 year survival for different ages, ASA, creatinine and aneurysm sizes. RESULTS: Overall survival was 93% at 1 year, 80% at 3 years and 67% at five years. Survival rates were found to be statistically associated with ASA, age, aneurysm size and creatinine levels. ASA has the largest effect. Five year survival rates for aneurysms >or=65 mm and <55 mm were 54% and 76% respectively. Pre-operative creatinine levels >or=160 micromol/L lowered the survival rate from 71% to 40%. CONCLUSIONS: Survival for EVAR patients is strongly correlated with a number of pre-operative factors. This survival analysis provides a useful decision-making tool for surgeons particularly for individuals with smaller aneurysms.

Preoperative nutritional status predicts the severity of the systemic inflammatory response syndrome (SIRS) following major vascular surgery.

OBJECTIVES: This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery. DESIGN AND METHODS: Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery. RESULTS: Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices. CONCLUSIONS: Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.

Arm vein as a last autogenous option for infrainguinal bypass surgery: it is worth the effort.

OBJECTIVES: Considerable evidence exists for the use of arm vein conduit in lower limb bypass surgery. The use of arm vein in preference to synthetic conduit as a last autogenous option was assessed for patency and limb salvage outcomes. MATERIALS AND METHODS: A prospective database was interrogated and checked against TQEH operating theatre database to detect all infrainguinal arm vein bypasses performed between 1997 and 2005. Patency, limb salvage and survival data for 37 arm vein bypasses was calculated using the Kaplan-Meier survival estimate method. RESULTS: There were no perioperative deaths. 30 day patency rates were 89% primary, 95% secondary and 95% limb salvage. 12 month patency rates were 56% primary, 79% secondary and 91% limb salvage. 5 year patency rates were 37% primary, 76% secondary and 91% limb salvage. There was no significant patency advantage for primary vs. "redo" grafts (p=0.54), single vessel vs. spliced conduits (p=0.33) or popliteal vs tibial outflow (p=0.80). Patient survival rate was 92% and 65% at 1 and 5 years respectively. CONCLUSION: Lower limb bypasses using arm vein can be performed with favourable patency and limb salvage compared to synthetic conduits. However, secondary interventions are frequently required to maintain patency. We recommend a vigilant surveillance program for early identification of patency threatening disease.

Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins.

BACKGROUND: The aim was to compare early postoperative subjective outcome measures in a randomized trial of multiple stab incision phlebectomy (MSIP) and transilluminated powered phlebectomy (TIPP) for the treatment of varicose veins. METHODS: Patients having surgery for varicose veins were randomized to receive either MSIP or TIPP for local avulsion of varicose veins. Operating time, number of incisions and postoperative outcome were analysed in both groups. Quality of life (QoL) was analysed before and 1 and 6 weeks after surgery using domain-specific (Burford pain scale), disease-specific (Aberdeen Varicose Vein Questionnaire) and generic (Short Form 36 and EuroQol 5D) instruments. RESULTS: Sixty-six patients consented to participate in the trial but four withdrew before surgery, so 33 patients underwent MSIP and 29 patients had TIPP. All patients had symptomatic or complicated varicose veins. There was no significant difference between groups in the total duration of surgery or the time taken for the avulsions. The number of incisions was significantly lower with TIPP. However, skin bruising at 1 and 6 weeks, and Burford pain score at 6 weeks were significantly higher in the TIPP group (P < 0.01 for bruising and P = 0.019 for pain). TIPP also had a greater adverse impact on generic QoL, resulting in a more prolonged recovery. CONCLUSION: TIPP had the advantage of fewer surgical incisions, but was associated with more extensive bruising, prolonged pain and reduced early postoperative QoL.

Trends in the presentation and surgical management of the acute diabetic foot.

BACKGROUND: This study examines trends in the presentation and surgical management of acute diabetic foot problems in a single institution. METHOD: Prospective audit of all diabetic patients who had a primary procedure for critical lower limb ischaemia (CLI) and/or foot sepsis between 1st January 1990 and 31st December 2002. Primary and secondary intervention, mortality and limb salvage rate within 6 weeks of the index procedure were recorded. RESULTS: There were 661 patients (417 men and 244 women of median age 69, range 31-99, years) with 799 affected limbs. CLI alone was present in 625 (78%) limbs, combined CLI and foot sepsis in 53 (7%) and foot sepsis alone in 121 (15%). The primary intervention was minor amputation in 323 (40%) limbs, revascularisation in 288 (36%), major amputation in 185 (23%) and sympathectomy in three limbs. Within 6 weeks, 125 (16%) limbs required secondary intervention, the peri-procedural mortality rate was 38 of 924 (4%), and the limb salvage rates for patients with CLI, combined CLI and sepsis and sepsis alone were 66, 66 and 80%, respectively. There was a significant decline in the proportion of patients presenting with CLI alone and a significant increase in the proportion presenting with combined CLI and sepsis and sepsis alone. In patients with CLI alone, there was a significant increase in the primary major amputation rate and a significant decline in the minor amputation rate with no significant change in the revascularisation rate. CONCLUSION: There has been a progressive decline in the proportion of patients presenting with CLI alone and a greater proportion of patients presenting with an element of foot sepsis. In patients with CLI alone, the primary major amputation rate has increased at the expense of a decline in minor amputation rate.

Predictors of success following endovascular aneurysm repair: mid-term results.

OBJECTIVE: Australian cases of endovascular aneurysm repair (EVAR) performed between 1999 and 2001 have been evaluated to determine the mid-term (6 months to 5 years) safety and efficacy of the procedure. This study looks at predictors of success, based on mid-term follow-up data. DESIGN OF STUDY: This study uses results obtained from a prospective semi-voluntary register (audit) of Australian data obtained from surgeons in the private and public sector. RESULTS: Peri-operative mortality for patients enrolled in the audit was 1.8%. Ninety-three percent of procedures were technically successful (890/961). Nearly 13% of patients have had re-interventions (mostly endoluminal) at follow-up. Analysis of audit data shows that the likelihood of experiencing post-operative complications or requiring additional procedures increases with ASA rating, increasing age, large pre-operative aneurysm size, aneurysm angle >45 degrees and number of co-morbid conditions diagnosed. CONCLUSIONS: This study confirms satisfactory mid-term results in a, national rather than unit specific, setting. Predictors of clinical failure or need for re-intervention include large aneurysm size, neck angulation >or=45 degrees and short infrarenal neck.

Systematic review of endovenous laser treatment for varicose veins.

BACKGROUND: The safety and effectiveness of endovenous laser treatment (EVLT) for varicose veins are not yet fully evaluated. METHODS: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to September 2004. Only case series were available for inclusion in the review. RESULTS: : Thirteen studies met the inclusion criteria. Self-limiting features, such as pain, ecchymosis, induration and phlebitis, were commonly encountered after treatment. Deep vein thrombosis and incorrect placement of the laser in vessels were uncommon adverse events. No study has yet assessed the effectiveness of laser therapy in comparison to saphenofemoral junction ligation with saphenous vein stripping. Occlusion of the saphenous vein and abolition of venous reflux occurred in 87.9-100 per cent of limbs, with low rates of re-treatment and recanalization. CONCLUSION: From the low-level evidence available it seems that EVLT benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion and reflux may alter with longer follow-up. The lack of such data, in addition to the small numbers of patients in the available studies, demonstrates the need for a randomized clinical trial of EVLT versus conventional surgery.