New diagnostic and treatment strategies in renal artery stenosis: a promising pursuit or disappointment foretold?

Clinical management of renal artery stenosis has seen a major shift, after randomised clinical trials have shown no group benefit of endovascular intervention relative to optimal medical control. However, the inclusion criteria of these trials have been criticised for focusing on a subset of patients with atherosclerotic renal artery stenosis where intervention was unlikely to be beneficial. Moreover, new imaging and computational techniques have become available, which have the potential to improve identification of patients that will respond to interventional treatment. This review addresses the challenges associated with clinical decision making in patients with renal artery stenosis. Opportunities for novel diagnostic techniques to improve patient selection are discussed, along with ongoing Dutch studies and network initiatives that investigate these strategies.

Safety and long-term effects of renal denervation: Rationale and design of the Dutch registry.

BACKGROUND: Percutaneous renal denervation (RDN) has recently been introduced as a treatment for therapy-resistant hypertension. Also, it has been suggested that RDN may be beneficial for other conditions characterised by increased sympathetic nerve activity. There are still many uncertainties with regard to efficacy, safety, predictors for success and long-term effects. To answer these important questions, we initiated a Dutch RDN registry aiming to collect data from all RDN procedures performed in the Netherlands. METHODS: The Dutch RDN registry is an ongoing investigator-initiated, prospective, multicentre cohort study. Twenty-six Dutch hospitals agreed to participate in this registry. All patients who undergo RDN, regardless of the clinical indication or device that is used, will be included. Data are currently being collected on eligibility and screening, treatment and follow-up. RESULTS: Procedures have been performed since August 2010. At present, data from 306 patients have been entered into the database. The main indication for RDN was hypertension (n = 302, 99%). Patients had a mean office blood pressure of 177/100 (±29/16) mmHg with a median use of three (range 0-8) blood pressure lowering drugs. Mean 24-hour blood pressure before RDN was 157/93 (±18/13) mmHg. RDN was performed with different devices, with the Simplicity™ catheter currently used most frequently. CONCLUSION: Here we report on the rationale and design of the Dutch RDN registry. Enrolment in this investigator-initiated study is ongoing. We present baseline characteristics of the first 306 participants.

Hemodynamic significance of collateral blood flow in chronic venous obstruction.

INTRODUCTION: Complaints related to the post-thrombotic syndrome do not always correlate well with the extent of post-thrombotic changes on diagnostic imaging. One explanation might be a difference in development of collateral blood flow. The aim of this study is to investigate the hemodynamic effect of collateralisation in deep venous obstruction. METHODOLOGY: Resting intravenous pressure of the common femoral vein was measured bilaterally in the supine position of patients with unilateral iliofemoral post-thrombotic obstruction. In addition, pressure in control limbs was also measured in the common femoral vein after sudden balloon occlusion in the external iliac vein. RESULTS: Fourteen patients (median age 42 years, 12 female) were tested. In eleven limbs post-thrombotic disease extended below the femoral confluence. Median common femoral vein pressure was 17.0 mmHg in diseased limbs compared to 12.8 mmHg in controls (p = 0.001) and 23.5 mmHg in controls after sudden balloon occlusion (p = 0.009). Results remained significant after correcting for non-occlusive post-thrombotic disease. CONCLUSION: This study shows that common femoral vein pressure is increased in post-thrombotic iliofemoral deep venous obstruction, though not as much as after sudden balloon occlusion. The latter difference could explain the importance of collateralisation in deep venous obstructive disease and the discrepancy between complaints and anatomical changes; notwithstanding, the presence of collaterals does not eliminate the need for treatment.

Contemporary management of the demanding infra-renal neck in abdominal aortic aneurysm repair.

Proximal infrarenal neck anatomy is a crucial factor in determining outcome of abdominal aortic aneurysm (AAA) repair. Unfavorable or demanding infrarenal neck anatomy significantly increases the complexity of both standard endovascular and open repair resulting in increased rates of morbidity and mortality. While technological improvements and expanding institutional experience have resulted in an increased proportion of patients with an AAA with unfavorable infrarenal neck treated by (fenestrated) endovascular techniques, open repair has also remained a valid technique. The purpose of this manuscript was to describe the wide array of endovascular and open techniques in use to treat patients with an AAA with a demanding infrarenal neck and discuss their results and indications.

Strategies to prevent spinal cord ischemia in thoracoabdominal aortic aneurysm repair.

Spinal cord ischemia (SCI) after thoracic and thoracoabdominal aortic aneurysm repair is a devastating complication, which happens after both open and endovascular repair. Incidence of SCI varies widely in the literature. Many factors during preoperative, operative and postoperative phases influence this incidence. The purpose of this article was to provide an overview on all factors influencing SCI and to report on the evidence in the literature about how to prevent SCI.

Septocutaneous tensor fasciae latae perforator flap for breast reconstruction: radiological considerations and clinical cases.

INTRODUCTION: The deep inferior epigastric artery perforator (DIEP) flap is the first choice in autologous breast reconstruction; in cases when it cannot be used, alternative flaps are available. A radiological study and clinical cases using septocutaneous tensor fasciae latae (sc-TFL) flap for breast reconstruction are presented. MATERIALS: Magnetic resonance angiographies (MRAs) of 55 patients were evaluated. The pedicle and the perforators of the TFL were studied. Five consecutive sc-TFL flaps for breast reconstruction were performed. RESULTS: Thirty-seven MRA scans were included. There was a mean of 1.5 septocutaneous perforators per thigh. The mean pedicle length was 8.3 cm. Every perforator originated from a branch of the lateral circumflex femoral artery (LCFA). The LCFA originated from the arteria femoralis profunda in 89.2% of cases. In the vertical plane, the mean distance of the perforator from the antero-superior iliac spine was 8.7 cm. There were no major complications in the five sc-TFL performed. CONCLUSION: On MRA, the septocutaneous pedicle of the TFL perforator flap was consistently present. MR angiographic assessment of the septocutaneous branches was very helpful in the preoperative evaluation of our patients. Dissection of the sc-TFL can be performed in a supine position simultaneously with mastectomy and/or dissection of the mammary vessels. Finally, the donor-site scar can be hidden by underwear, giving minimal deformity. We recommend the sc-TFL flap as a good alternative to the DIEP flap for autologous breast reconstruction. Preoperative imaging is mandatory for correct planning of the flap.

The current endovascular therapeutic spectrum for short neck and juxtarenal aneurysms.

Endovascular treatment of short neck infrarenal and juxtarenal abdominal aortic aneurysms (AAA) is feasible. Many different techniques have been used, including standard stent-grafts with or without adjuncts as endoanchors or chimney grafts, fenestrated stent-grafts or even newer concepts like the multilayer flow modulating stent. The purpose of this article was to describe the techniques, the indications and results of the various endovascular methods to treat short neck infrarenal and juxtarenal AAA.

CTA with fluoroscopy image fusion guidance in endovascular complex aortic aneurysm repair.

OBJECTIVES: To evaluate the effect of intraoperative guidance by means of live fluoroscopy image fusion with computed tomography angiography (CTA) on iodinated contrast material volume, procedure time, and fluoroscopy time in endovascular thoraco-abdominal aortic repair. METHODS: CTA with fluoroscopy image fusion road-mapping was prospectively evaluated in patients with complex aortic aneurysms who underwent fenestrated and/or branched endovascular repair (FEVAR/BEVAR). Total iodinated contrast material volume, overall procedure time, and fluoroscopy time were compared between the fusion group (n = 31) and case controls (n = 31). Reasons for potential fusion image inaccuracy were analyzed. RESULTS: Fusion imaging was feasible in all patients. Fusion image road-mapping was used for navigation and positioning of the devices and catheter guidance during access to target vessels. Iodinated contrast material volume and procedure time were significantly lower in the fusion group than in case controls (159 mL [95% CI 132-186 mL] vs. 199 mL [95% CI 170-229 mL], p = .037 and 5.2 hours [95% CI 4.5-5.9 hours] vs. 6.3 hours (95% CI 5.4-7.2 hours), p = .022). No significant differences in fluoroscopy time were observed (p = .38). Respiration-related vessel displacement, vessel elongation, and displacement by stiff devices as well as patient movement were identified as reasons for fusion image inaccuracy. CONCLUSION: Image fusion guidance provides added value in complex endovascular interventions. The technology significantly reduces iodinated contrast material dose and procedure time.

Coronary artery-bronchial artery fistulas: report of two Dutch cases with a review of the literature.

BACKGROUND: Coronary bronchial artery fistulas (CBFs) are rare anomalies, which may be isolated or associated with other disorders. MATERIALS AND METHODS: Two adult patients with CBFs are described and a PubMed search was performed using the keywords "coronary bronchial artery fistulas" in the period from 2008 to 2013. RESULTS: Twenty-seven reviewed subjects resulting in a total of 31 fistulas were collected. Asymptomatic presentation was reported in 5 subjects (19 %), chest pain (n = 17) was frequently present followed by haemoptysis (n = 7) and dyspnoea (n = 5). Concomitant disorders were bronchiectasis (44 %), diabetes (33 %) and hypertension (28 %). Multimodality and single-modality diagnostic strategies were applied in 56 % and 44 %, respectively. The origin of the CBFs was the left circumflex artery in 61 %, the right coronary artery in 36 % and the left anterior descending artery in 3 %. Management was conservative (22 %), surgical ligation (11 %), percutaneous transcatheter embolisation (30 %), awaiting lung transplantation (7 %) or not reported (30 %). CONCLUSIONS: CBFs may remain clinically silent, or present with chest pain or haemoptysis. CBFs are commonly associated with bronchiectasis and usually require a multimodality approach to be diagnosed. Several treatment strategies are available. This report presents two adult cases with CBFs and a review of the literature.

Value of magnetic resonance venography and computed tomographic venography in lower extremity chronic venous disease.

For the treatment of chronic venous disease (CVD) of the lower extremity, identification of the underlying venous pathologies is essential. Traditionally, the pathologies to detect with imaging have been centred on insufficiency and reflux of the superficial, perforator and deep veins of the leg. More recently, stenosis and obstruction of the deep veins of the pelvis and abdomen (i.e. inferior vena cava, common and external iliac veins) have been identified as significant underlying pathologies in CVD. Accurate detection of stenotic and/or occlusive venous disease expands the treatment options for patients with CVD. In most cases, imaging of venous disease is performed with duplex ultrasound. In this article we discuss the existing evidence and potential value of computed tomographic venography and magnetic resonance venography to contribute in accurately identifying chronic venous disease, in particular chronic venous obstruction.

Spinal cord function monitoring during endovascular treatment of thoracoabdominal aneurysms: implications for staged procedures.

AIM: Spinal cord ischemia is a well-known complication in the treatment of thoracoabdominal aneurysms (TAAA). Despite the fact that endovascular treatment of TAAA is less invasive, spinal cord ischemia rate is not reduced if compared to open repair. METHODS: We report the results of our experience of spinal cord function monitoring by measuring motor evoked potentials (MEP) during endovascular treatment of TAAA type II and III. Depending on the level of the MEPs the decision is made whether to stage the procedure or not. We treated ten patients according to this protocol. RESULTS: In two patients, MEPs decreased 50% or more and procedures were staged. Both experienced no neurological complications after first and second procedure. No MEPs decrease was seen during the second procedures. One of the other eight patients had a temporary right lower leg pararesis. CONCLUSION: In conclusion we state that our first experience demonstrates the value of assessing spinal cord function during extensive endovascular TAAA repair with subsequent strategies to prevent paraplegia.

Plasma levels of matrix metalloproteinase-9: a possible diagnostic marker of successful endovascular aneurysm repair.

OBJECTIVE: The aim of the study was evaluating the diagnostic value of plasma matrix metalloproteinase- (MMP)-2 and -9 and tissue inhibitor of MMP-1 (TIMP-1) for endoleak detection after endovascular aneurysm repair (EVAR). REPORT: Consecutive EVAR patients (n = 17) with endoleak and matched controls without endoleak (n = 20) were prospectively enrolled. Increased levels of MMP-9 were observed in patients with endoleak (P < 0.001). Regression analysis showed no significant influence of age, sex or abdominal aortic aneurysm (AAA) size. The receiver operating characteristic (ROC) curve of plasma MMP-9 levels showed that a cut-off value of 55.18 ng ml(-1) resulted in 100% sensitivity and 96% specificity with an AUC value of 0.988 (P < 0.001) to detect endoleak. CONCLUSIONS: Plasma MMP-9 levels appear to discriminate between patients with and without an endoleak with high sensitivity and specificity.

[Peripheral artery disease: clinical and cost comparison between duplex ultrasonography and contrast-enhanced magnetic resonance angiography--a multicenter randomized trial]. / De kosten en de effecten van magnetischeresonantieangiografie en duplexechografie bij patiënten met perifeer arterieel vaatlijden: een multicentrische gerandomiseerde studie.

OBJECTIVE: To determine the clinical and economic consequences of replacing duplex ultrasonography (DUS) by contrast-enhanced magnetic resonance angiography (CE-MRA) for the initial diagnostic work-up of patients with peripheral artery disease (PAD). DESIGN: Randomised multicentre study. METHOD: In the period from January 2002 to August 2003, consecutive patients with PAD were randomly assigned to CE-MRA or DUS. The primary outcome measure was the costs. Secondary outcome measures included the confidence with which the specialist could take a therapeutic decision on the basis of the imaging study, the change in disease severity, and the change in quality of life (QOL) assessed during 6 months of follow-up. In addition, all costs of imaging, therapeutic interventions and outpatient visits were calculated. RESULTS: After 6 months of follow-up the data on 352 patients were analysed. Use of CE-MRA reduced the number of additional vascular-imaging procedures by 42% ((69-40)/69) and the specialists felt more confident about their therapeutic decisions. The diagnostic costs of all imaging studies taken together were Euro 167,- higher, on average, in the CE-MRA group (p < 0.001). However, after 6 months of follow-up, no statistically significant differences were found between the two groups with regard to the change in disease severity, the QOL, or the total costs (p > 0.05). CONCLUSION: Based on these findings, a specialist that replaces DUS by CE-MRA will feel more confident about taking a therapeutic decision and will feel less need for additional imaging. However, the diagnostic costs were higher with CE-MRA.

Current techniques for assessment of upper extremity vasculature prior to hemodialysis vascular access creation.

Vascular access problems lead to increased patient morbidity and mortality and place a large burden on care facilities, manpower and costs. Autogenous arteriovenous fistulas (AVF) are preferred over arteriovenous grafts (AVG) because of a lower incidence of vascular access related complications. An aggressive increase in the utilization of AVF, however, results in an increased incidence of AVF early failure and non-maturation. Increasing evidence suggests that routine preoperative assessment results in an increased utilization of functioning AVF by better selection of adequate vessels. To date, the reproducibility and standardization of assessment protocols are lacking and assessment of a single morphological parameter has not enabled adequate prediction of postoperative AVF function for individual patients. In this paper, we provide an overview of available diagnostic modalities and parameters that potentially enable better selection of adequate vessels for successful AVF creation.

Severe anal bleeding in Proteus syndrome: a case report.

Proteus syndrome was originally described by Cohen and Hayden in 1979. The disorder was named Proteus syndrome by Wiedmann and colleagues in 1983 after Proteus, the giant Greek god of the sea. Proteus syndrome is a rare, sporadic, congenital polymorphic condition. Approximately 200 cases have been reported in the literature, but none has been associated with anal bleeding from hemorrhoids. We describe the case of a 21-year-old man with Proteus syndrome with severe anal bleeding. A hemorrhoidectomy was assumed to be too risky because of the massive venous abnormalities seen on CT. The patient was successfully treated by Doppler-guided haemorrhoidal artery ligation (DG-HAL). Six months after surgery, the patient has had no further episodes of anal bleeding.

Endovascular treatment of traumatic rupture of the thoracic aorta.

BACKGROUND: Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the 'gold standard', but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative. METHODS: A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up. RESULTS: A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1.5 per cent. Some 6.7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14.4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias. CONCLUSION: Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.

Autogenous options in secondary and tertiary access for haemodialysis.

OBJECTIVES: The world's haemodialysis population is growing rapidly so that in 2006, some 1.5 million interventions will be needed for access placement, revision and maintainance. Secondary and tertiary arteriovenous fistulas are becoming an integral part of vascular access especially in the elderly, comorbid population. METHODS: Venous conduits may have a more favourable outcome with fewer complications and revisions in comparison with accesses using prosthetic implants. Innovative surgical techniques, including vein transposition, translocation and elevation may add to this philosophy of creating exclusively autogenous vascular access.

Contemporary imaging techniques for the diagnosis of renal artery stenosis.

Renal artery stenosis (RAS) is a potentially curable cause of renovascular hypertension (RVH) and is caused by either atherosclerosis or fibromuscular dysplasia (FMD) in the vast majority of patients. Although intra-arterial digital subtraction angiography (IA-DSA) is still considered the standard of reference test for the anatomical diagnosis of RAS, noninvasive techniques such as MR angiography, CT angiography, and color-aided duplex ultrasonography are promising alternatives that also allow functional characterization of RAS. We provide an overview of these techniques and discuss their relative merits and shortcomings. Analysis of high-quality studies shows that both MR and CT angiography are significantly more accurate for the diagnosis of at least 50% atherosclerotic RAS than ultrasonographic techniques. The primary strength of ultrasonography at present is its suggested ability to predict functional recovery based on preinterventional resistance index measurements. A still unresolved issue is the detection of FMD. Because missing RVH may have serious consequences the most important requirement for a screening test is that it has high sensitivity.

Current topics on vascular access for hemodialysis.

Vascular access remains the lifeline for end-stage renal failure patients, which have been treated by chronic intermittent hemodialysis. Due to the steady increase in the number of patients with difficulties to create access, in particular in elderly with various comorbidities, the need for more insight and regulations have evolved into the publications of the American and European guidelines. From the latter it may be obvious that an adequate preoperative assessment followed by the creation of autogenous arteriovenous fistulas (AVFs) is far better and preferred to the implantation of grafts. Vascular access maintenance by monitoring and elective percutanuous or surgical revision is of utmost importance to keep the access site functional. Despite up-to-date measures for vascular access maintenance, various complications may treaten not only the access site but also quality and expectance of life. Thrombotic occlusion remains a major event, leading to permanent failure in 10% of AVFs and 20% of grafts each year. Interventional (percutaneous transluminal angioplasty and/or stent implantation) or surgical revision of thrombosed accesses have similar outcomes with a high rate of reinterventions. The elderly diabetic population with peripheral arteriosclerotic obstructive disease is in particular prone to angio-access induced handischemia. When not timely and properly treated this may lead to minor or major amputation, further hampering quality of life. Also, the enormous application in the past 2 decades of acute central venous lines has lead to a significant increase of central venous obstruction with concomittent morbidity and problems creating vascular access in the upper extremities. Radiological intervention in these cases is a primary option, leaving surgical reconstruction as a second best method. It may be obvious that creation and maintenance of hemodialysis vascular access has become an important and time-consuming speciality. Only an up-to-date multidisciplinary management with involvement of nurses, nephrologists, interventionalists and surgeons, will lead to the desired outcome.