Vascular

To determine the outcomes of type II endoleak embolization with aneurysm sac obliteration and whether the approach – direct sac puncture or transarterial – affects outcome.

A retrospective review of patients who underwent endovascular aneurysm repairs and subsequent type II endoleak embolization over 10 years was performed. Twenty-three patients (median age: 73 years, range: 40–88 years) underwent 35 embolizations. Embolization was performed with the goal of obliterating both the endoleak sac and feeding vessels. Embolization agents used include cyanoacrylate glue only (48%), glue and coils (36%), coils only (13%), and other (3%).

Mean follow-up was 21.8 months. Patients underwent an average of 1.5 embolizations, with 35% requiring more than one. Technical success rate was 89%. Freedom from aneurysm sac expansion was achieved in 91%. Freedom from type II endoleak was accomplished in 70%. There were no ruptured aneurysms during the follow-up period. Direct sac puncture and transarterial approaches had similar incidences of aneurysm sac growth (p = 0.74), persistent type II endoleak (p = 0.32), and complications (p = 0.64). However, direct sac puncture had significantly shorter fluoroscopy (p < 0.001) and total procedure times (p < 0.001) than transarterial embolizations.

Direct sac puncture and transarterial embolization of type II endoleak with aneurysm sac obliteration are similarly effective for the prevention of aneurysm sac growth. However, direct sac puncture is our preferred approach given its significantly shorter fluoroscopic and procedural times.

Endovascular treatment of pararenal abdominal aortic aneurysm has gained terrain over the past decade, despite the substantial need for reinterventions during follow-up. However, open repair is still a well-established treatment option. With the current study we report the results of a consecutive series of elective primary open pararenal abdominal aortic aneurysm repair in a tertiary vascular referral centre, combined with an overview of current literature and pooled data analysis of perioperative mortality of open and endovascular pararenal abdominal aortic aneurysm repair.

A retrospective analysis of a prospective database of all elective open pararenal abdominal aortic aneurysm repairs in the St. Antonius Hospital between 2005 and 2014 was performed. Primary endpoint was 30-day mortality. Secondary endpoints were 30-day morbidity, new onset dialysis, reintervention free survival, and overall survival during follow-up.

Between 2005 and 2014, 214 consecutive patients underwent elective open pararenal abdominal aortic aneurysm repair. Mean age was 69.8 (±7.1) years, 82.7% (177/214) were men, and mean abdominal aortic aneurysm diameter was 62 (±11) mm. Thirty-day mortality was 3.4%. Thirty-day morbidity was 27.1%, which predominantly consisted of pneumonia (18.7% (40/214)), cardiac events (3.3% (7/214)), and new onset dialysis (2.8% (6/214)). Estimated five-year overall survival rate was 74.2%. 0.9% (2/214) of patients required abdominal aortic aneurysm-related reintervention, and an additional 2.3% (5/214) required surgical repair of an incisional hernia. Pooled analysis of literature revealed a 30-day mortality of 3.0% for open pararenal repair and 1.9% for fenestrated endovascular repair.

Open pararenal abdominal aortic aneurysm repair in the era of increasing endovascular options results in acceptable perioperative morbidity and mortality rates. Mid-term reintervention rate is low compared to fenestrated endovascular aneurysm repair. Expertise with open repair still remains essential for treatment of pararenal abdominal aortic aneurysms in the near future, especially for those patients that are declined for endovascular treatment.

The development and use of minimally invasive procedures provide improved options for the management of symptoms of chronic venous insufficiency. While many patients with iliac venous occlusive disease and superficial venous insufficiency improve with combined iliac venous stenting and correction of superficial venous reflux, some patients have symptoms which persist. The goal of this study was to identify clinical factors related to persistent symptoms in patients with leg swelling after treatment of both iliac vein stenting and thermal ablation.

This observational study analyzed data for patients who underwent both iliac vein stent placement as well as endovenous ablation (either RFA or EVLT) as a management for chronic venous insufficiency between February 2012 and February 2014. Follow-up was performed after completion of both procedures and inquiring for improvement of swelling. Statistical analysis performed using Chi-square and student's t-test.

Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 55 (31.8%) patients were men; 29 (16%) patients stated they had no improvement after these procedures. The average age of patients who did not improve was 68.8 (±16.7 SD) years and 66.2 (±13.3 SD) years for patients who improved. Over all, the classification of the presenting symptoms by CEAP classification demonstrated 25.4%, 53.2%, 5.8%, and 15.6%, for C3–C6, respectively. There was no correlation with failure to improve the swelling with: age (P = .44), gender (P = .33), presenting symptom (P = .67), use of calcium channel blockers (P = .85), nitroglycerin (P = .86), Plavix (P = .07), aspirin (P = .55), Synthyroid (P = .55), Coumadin (P = .14), angiotensin receptor blocker (P = .81), β Blockers (P = .61), angiotensin converting enzyme inhibitors (P = .88), furosemide 40 mg (P = .74), hydrochlorothiazide 12.5 mg (P = .07), hydrochlorothiazide 25 mg (P = .48), and EVLT vs. RFA (P = .91). The use of furosemide (20 mg) was associated with continued swelling (P = .01). The use of dual diuretics (furosemide and hydrochlorothiazide) was associated with persistent swelling even after these combined endovenous procedures P = .03).

These preliminary data suggest that the treatment with diuretics may be associated with failure to relieve lower extremity swelling despite combined endovascular therapy for chronic venous insufficiency.

Pelvic vein incompetence is a cause for pelvic pain and recurrent varicose veins in women. The gold standard diagnostic method is reflux venography involving radiation, nephrotoxic contrast and jugular puncture. Trans-vaginal ultrasound (TVU) is increasingly being used as a diagnostic tool for pelvic vein incompetence.

Fifty women with clinical suspicion of pelvic vein incompetence and aged between 18 and 55 years were recruited prospectively over two years at a large UK University Teaching Hospital. Trans-vaginal ultrasound was performed using a standardised protocol which included assessment of the ovarian and internal iliac veins bilaterally in the supine and semi-standing position with provocative manoeuvres. Diagnostic readability and inter-observer variability was determined.

Mean (range) age of 43 (23–51). Visibility of all four pelvic veins was better in the supine position compared with semi-standing position (76% vs 64%). Pelvic vein incompetence was identified in 34 of 50 (68%) women in the supine position compared with 38 of 50 (76%) women in the semi-standing position. Pelvic vein incompetence was demonstrated in 35 of 50 (70%) women with Valsalva manoeuvre. Inter-observer variability was 0.84 (kappa, very good agreement, p = 0.001).

Trans-vaginal ultrasound is effective at demonstrating pelvic vein incompetence. All trans-vaginal ultrasound protocols should include assessment of pelvic veins in the supine and semi-standing position with Valsalva manoeuvre.

The aim of this paper is to report our experience of type II endoleak treatment after endovascular aneurysm repair with intra-arterial injection of the embolizing liquid material, Onyx liquid embolic system.

From 2005 to 2012, we performed a retrospective review of 600 patients, who underwent endovascular repair of an abdominal aortic aneurysm. During this period, 18 patients were treated with Onyx for type II endoleaks.

The source of the endoleak was the internal iliac artery in seven cases, inferior mesenteric artery in seven cases and lumbar arteries in four cases. Immediate technical success was achieved in all patients and no endoleak from the treated vessel recurred. During a mean follow-up of 19 months, no major morbidity or mortality occurred, and one-year survival was 100%.

Treatment of type II endoleaks with Onyx is safe and effective over a significant time period.

We studied the association between secondhand smoke (SHS) exposure and peripheral arterial disease (PAD) in Chinese non-smokers.

We conducted a cross-sectional study using baseline data from the Guangzhou Biobank Cohort Study: Cardiovascular Disease Sub-cohort Study (GBCS-CVD). Guangzhou residents aged ≥ 50 years were recruited between 2003 and 2008. Baseline data included measurement of ankle brachial pressure index (ABPI) and self-reported smoking status and SHS exposure. Univariate and multivariate logistic regression analyses were used to analyze the association between SHS and PAD (defined as ABPI < 0.9).

Of the 1507 non-smokers, 24 (1.6%) had PAD. Of these, 12 were men and 12 were women. Exposure to SHS at home of ≥25 h per week was reported by 16.7% of PAD cases compared with 3.8% of those without PAD (χ2 test, p = 0.003). After adjustment for potential confounders, exposure to ≥25 h per week at home was still associated with PAD (adjusted OR 7.86, 95% CI 2.00–30.95, p = 0.003), with suggestion of a dose-response relationship.

Our results extend the US Surgeon General’s 2006 report that SHS exposure is an independent risk factor for PAD. National smoke-free legislation is needed to protect all people from exposure.

Platelet-to-lymphocyte ratio is a novel biomarker, recently shown to be correlated with atherosclerotic inflammation. This study investigated the role of platelet-to-lymphocyte ratio in patients with carotid artery stenosis and stroke.

Patients, who underwent carotid angiography with Multiple Detector Computed Tomography Angiography at our hospital, were retrospectively screened. Patients enrolled were divided into three groups based on the platelet-to-lymphocyte ratio. Patients with a platelet-to-lymphocyte ratio value between 55.0 and 106.71 were assigned to Group I, patients with a platelet-to-lymphocyte ratio value between 106.79 and 160.61 were assigned to Group II and patients with a platelet-to-lymphocyte ratio value between 162.96 and 619.61 were assigned to Group III. The carotid arterial stenosis calculated was classified as per the criteria of North American Symptomatic Carotid Endarterectomy Trial.

One hundred fifty patients were included in our trial (mean age 61.9 ± 13.1 with 104 males). The rate of carotid arterial stenosis was detected to be higher in patients with a high platelet-to-lymphocyte ratio value (p = 0.010). Additionally, the platelet-to-lymphocyte ratio was positively correlated with the carotid arterial stenosis percentage (r = 0.250, p = 0.002). In the multi-variate regression analysis, platelet-to-lymphocyte ratio was detected to be an independent variable with respect to stroke (odd’s ratio = 1.012, confidence interval = 1.001–1.024, p = 0.031).

Increased platelet-to-lymphocyte ratio could be a simple and practical marker of the clinical course in patients with carotid arterial stenosis.

Complete thrombosis of an aortic endograft after an endovascular aortic aneurysm repair is a rare complication. The majority of thrombotic events occur in the iliac limbs.

We present the case of a patient who presented with acute limb ischemia as the result of a thrombosed infra-renal aortic endograft. After restoration of blood flow to the lower extremities with an axillary to bi-femoral artery bypass, the patient was lost to follow-up. The patient returned two years later with a ruptured abdominal aortic aneurysm due to a type 1A endoleak.

We propose that all patients after endovascular aortic aneurysm repair, including those with a thrombosed aortic endograft, continue to undergo regular graft surveillance. This case report highlights the importance of continued surveillance of the aortic sac, even after total thrombosis of the endovascular aortic aneurysm repair.