Perspectives in Vascular Surgery and Endovascular Therapy

Infrainguinal arterial bypass with autologous vein has proven effective and durable over nearly 60 years. Less invasive endovascular treatment has emerged as a formidable competitor to the vein bypass. In many, if not most cases, the choice of one modality over the other is clear. However, there are situations where the decision is not so obvious. It is in such cases that the careful consideration of all patient and anatomic factors by the experienced vascular specialist who can offer both open surgical bypass and endovascular treatment is likely to lead to better outcomes. This article and presentation will attempt to provide some guidelines that the reader may consider when making such choices.

Multiple endovascular interventions exist for the treatment of lower extremity peripheral arterial disease (PAD), with some exhibiting better outcomes than others. As these procedures become more numerous and accepted, the type of interventionalist providing the care is changing. Despite advances in technology and techniques, there are many obstacles to overcome in order to improve the treatment of patients with vascular disease. These can be divided into managing recurrent disease, protection of the distal vasculature, and the prevention of disease. Studies are already underway in areas involving drug-eluting balloons and stents for the periphery, brachytherapy, bioabsorbable stents, distal protection, and therapeutic angiogenesis. As knowledge about the treatment of peripheral arterial disease is acquired that can be applied to the concept of personalized health care, there is hope to be able to slow or arrest the progression of this disease.

The management of acute deep vein thrombosis (DVT) by medical therapy with anticoagulation has long been supported by evidence-based clinical practice guidelines outlined in the American College of Chest Physicians supplement. Early thrombus removal in patients with iliofemoral DVT has been reported to lead to improved venous valve function, improved quality of life, and decreased incidence of postthrombotic syndrome over anticoagulation alone. The ATTRACT trial will randomize patients to medical management with standard anticoagulation versus catheter-directed thrombolysis in addition to standard anticoagulation after stratification to iliofemoral versus femoropopliteal DVT in order to determine the primary outcome of postthrombotic syndrome over a 24-month follow-up.

Chronic venous insufficiency resulting from great saphenous vein (GSV) reflux is a problem seen with increasing frequency in most vascular surgical practices. Traditionally treated with high ligation and stripping, minimally invasive techniques for ablation of the GSV have evolved. These include endovenous laser surgery, radiofrequency ablation, and foam sclerotherapy. The authors discuss the mechanism of action of each modality, as well as the techniques for intervention, outcomes, and complications. Minimally invasive treatment of venous insufficiency is efficacious, with less morbidity than high ligation and stripping, allowing for successful treatment and improved patient satisfaction.

One of the most crucial steps in endovascular infrarenal abdominal aortic aneurysm repair is the short limb catheterization of the modular device and the confirmation of the intrastent position of the guidewire. Failed connection of the contralateral iliac limb to the main body because of malposition of the catheterizing guidewire may lead to serious complications. A new method confirming successful passage of the guidewire in the short leg of the main body of the modular stent graft, thus ensuring that the extension will be accurately docked within the short limb, is described in detail. Furthermore, current tips for ensuring successful short limb cannulation are also described in brief.

A left renal artery aneurysm (RAA) was incidentally discovered in a 50-year-old hypertensive woman at renal artery duplex scan. The computed tomography angiography scan confirmed an eccentric, 2-cm large aneurysm localized on a prehilar branch with a very twisted and coiled main renal artery. The selective digital subtraction angiography allowed a better understanding of the local complex anatomy; a covered stent was placed with the complete exclusion of the aneurysm. Even if open surgery still represents the treatment of choice, endoluminal approach has been reported as an effective procedure especially in consideration of its low invasiveness. The exclusion by covered stent can be a safe alternative to coil embolization in case of distal RAAs as well.

A quarter of all intertrochanteric fractures are unstable with a fractured lesser trochanter. Mostly these fractures are treated with a gamma nail fixation. A rare complication of this treatment is a false aneurysm of the femoral artery. The authors present 2 cases of a false aneurysm of the femoral artery in association with intertrochanteric fractures. Because of its nonspecific symptoms, a false aneurysm is difficult to diagnose. A computed tomography angiography or duplex should be used to confirm the diagnosis and evaluate the options for treatment. Surgery is the preferred treatment in the case of a large aneurysm, whereas endovascular repair is preferred for smaller aneurysms.

In the authors’ institution, 27 patients with gluteal injuries were treated surgically during the past 17 years. All patients were males, and the mean age was 32.4 years. Most patients (89%) had stab wounds. The lesion was on the right buttock in 16 (59%) patients and on the left buttock in 11 (41%) patients. Bleeding was the most common presenting sign. The superior gluteal artery and its branches were the most commonly injured arteries (89%). Surgical procedure was arterial ligation alone in all but one case, whereas one patient underwent coil embolization. Mortality was 11% and included 1 death on arrival to the medical center and 2 intraoperative deaths. To achieve a low rate of morbidity and mortality with such injuries, careful physical examination and immediate surgical or endovascular treatment is needed.

Venous ulcers affect almost 1 million people in the United States. Delayed healing and frequent recurrence result in pain, disability, decreased quality of life, and loss of working days for the patients. Compression therapy is the most effective treatment of ulcers, but compliance with conservative treatment is important, and recurrence must be prevented by treating the underlying ambulatory venous hypertension. Evidence from prospective randomized trials confirm that ulcer recurrence is decreased with superficial vein surgery. Evidence is also increasing about the superiority of endovenous interventions, such as laser or radiofrequency ablation, over the classic open surgical treatment of high ligation, division, and stripping of the saphenous vein. Well-conducted randomized trials are still needed to provide grade A evidence to justify treatment of incompetent perforating veins. Treatment of proximal venous occlusion is important, and venous stents have been effective and durable. Open surgery is only considered today for iliac or iliocaval venous obstruction if endovascular treatment is not possible or has already failed. Open surgery for deep venous incompetence is recommended in centers of excellence, although evidence to support its effectiveness is of low quality.