Ann Vasc Surg 2012; 26(5) Originals

1. Ann Vasc Surg. 2012 Jul;26(5):734-8. doi: 10.1016/j.avsg.2012.03.003.

Technical strategy for the endovascular management of ascending aortic pseudoaneurysm.

Gray BH, Langan EM 3rd, Manos G, Bair L, Lysak SZ. Source Department of Surgery, Greenville Hospital System University Medical Center, Greenville, SC 29615, USA. bhgray@ghs.org Abstract We present two cases of ascending aortic pseudoaneurysm exclusion with off-the-shelf aortic stent grafts. The right common carotid artery was used for access to facilitate graft delivery. Control of graft deployment was aided using a compliant right atrial occlusion balloon to lower cardiac output at the time of deployment. Transesophageal echocardiography facilitated the sizing and positioning of the right atrial balloon and was used to survey the heart and ascending aorta on successful exclusion of the pseudoaneurysm. These simple maneuvers made an uncommon procedure straight forward, predictable, and successful. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664284 [PubMed - indexed for MEDLINE] Related citations

2. Ann Vasc Surg. 2012 Jul;26(5):715-9. doi: 10.1016/j.avsg.2011.11.035.

Endoluminal treatment of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection.
Canaud L, Demaria R, Joyeux F, Hireche K, Berthet JP, D'Annoville T, Marty-An C, Alric P. Source

Department of Thoracic and Cardio-Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France. ludoviccanaud@hotmail.com Abstract BACKGROUND: The aim of this study was to evaluate the short- and midterm results following endovascular repair of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection. METHODS: Between 2003 and 2010, six consecutive patients previously operated for acute type A dissection underwent endovascular repair of dissecting aortic arch aneurysm (six men, mean age: 63 9.8 years); one of the aneurysms was ruptured. Follow-up computed tomography scans were performed at 1 week, at 3 and 6 months, and annually thereafter. RESULTS: All endografts were successfully deployed (TAG [2], Valiant [4]). All the patients underwent hybrid technique with supra-aortic debranching (through a sternotomy approach in four cases and through a cervical approach in two cases) and simultaneous or staged endovascular stent-grafting. During the same operative time, one patient underwent, on full cardiopulmonary bypass, saphenous vein bypass from the ascending aorta to the anterior descending coronary artery. One permanent neurologic event was observed. After a mean follow-up of 22.3 14.6 months, no aortic-related mortality was observed. No cases of stent-graft migration or secondary rupture were observed. The ruptured aortic arch aneurysm presented a type I endoleak at 6 months and was successfully treated with a second endograft. One patient died of an unrelated cause 7 months after surgical repair. CONCLUSIONS: Our experience demonstrates promising potential of endovascular repair of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection. The potential to diminish the magnitude of the surgical procedure and the consequences of aortic arch exposure, and above all avoiding the need for circulatory arrest, is promising and mandates further investigation to determine the efficacy and durability of this technique. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664283 [PubMed - indexed for MEDLINE] Related citations

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Ann Vasc Surg. 2012 Jul;26(5):693-9. doi: 10.1016/j.avsg.2011.12.003.

Surgery with vascular reconstruction for soft-tissue sarcomas in the inguinal region: oncologic and functional outcomes.
Emori M, Hamada K, Omori S, Joyama S, Tomita Y, Hashimoto N, Takami H, Naka N, Yoshikawa H, Araki N. Source Musculoskeletal Oncology Service, Osaka Medical Center Cardiovascular Diseases, Osaka, Japan. emrmkt@yahoo.co.jp Abstract BACKGROUND: Treatment of soft-tissue sarcomas involving the inguinal region remains challenging because of difficulties in achieving wide surgical margins due to anatomical features. The study aimed to analyze the oncologic and functional outcomes of wide resection with vascular reconstruction for inguinal soft-tissue sarcomas. METHODS: Three men and seven women were treated for inguinal soft-tissue sarcomas by wide surgical resection with vascular reconstruction. RESULTS: Arteries and veins were replaced in nine patients, and artery replacement alone was carried out in one patient. Femoral nerve resections were performed in six patients. One patient and five patients developed local recurrence and distant metastases, respectively. Limb salvage was achieved in 9 of 10 patients (90%). Six patients and one patient developed vascular (arterial graft occlusion [n = 1], lymphedema [n = 5]) and nonvascular (hematoma [n = 1]) complications, respectively. Five-year arterial primary patency was 77%. Five-year disease-free and overall survival rates were 45% and 77%, respectively. Functional outcome scores at latest follow-up averaged 87.5% for Musculoskeletal Tumor Society 1993. CONCLUSIONS: En-bloc resection of major critical structures along with tumor and vascular reconstructions using synthetic grafts is a feasible option in limb salvage surgery for inguinal soft-tissue sarcomas. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664282 [PubMed - indexed for MEDLINE] Related citations for Cancer and

4. Ann Vasc Surg. 2012 Jul;26(5):665-73. doi: 10.1016/j.avsg.2011.12.004.

The results of surgical treatment for patients with venous malformations.

Roh YN, Do YS, Park KB, Park HS, Kim YW, Lee BB, Pyon JK, Lim SY, Mun GH, Kim DI. Source Division of Vascular Surgery, Congenital Vascular Malformation Clinic, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Abstract BACKGROUND: The objective of this study was to estimate the outcomes of surgical treatment for patients with venous malformations (VMs). METHODS: We retrospectively reviewed the data of 48 patients who underwent surgical management for VMs from 1994 to 2009 at our institute. The 1-year responses to surgeries were classified into three groups based on the results: "remission," "improvement," and "no change." RESULTS: The indications of surgeries were mass or swelling in 48 patients (100%), intractable pain in 11 (23%), limb length discrepancy in seven (15%), bleeding in three (6%), and limitation of the range of motion in one (2%). The locations of the VMs were head and neck in 17 patients (35%), abdomen and pelvis in one (2%), perineum and genitalia in three (6%), upper extremities in 12 (25%), and lower extremities or buttocks in 15 (31%). Of the 48 surgeries for radical excision and debulking, 25 (52%) resulted in remission, 11 (23%) in improvement, and 12 (25%) in no change. During follow-up (mean: 44.8 36.6 months, range: 0-111 months), recurrence after radical excision occurred in 10% (3 of 31) of the patients, and size increase after debulking surgery in 24% (4 of 17) of the patients. CONCLUSIONS: Surgical treatment can be an option in patients with VMs, especially with symptoms that cannot be managed with conservative therapy or sclerotherapy. After excisional or debulking surgery in patient with VMs, remission or improvement can be observed in 75%.

Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664281 [PubMed - indexed for MEDLINE] Related citations

5. Ann Vasc Surg. 2012 Jul;26(5):636-42. doi: 10.1016/j.avsg.2011.11.036.

A genetic study of chronic venous insufficiency.

Serra R, Buffone G, de Franciscis A, Mastrangelo D, Molinari V, Montemurro R, de Franciscis S. Source Unit of Vascular Surgery, Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy. rserra@unicz.it Abstract BACKGROUND: Chronic venous insufficiency (CVI) is an important cause of morbidity in Western countries. The aim of this study is to demonstrate the heredity of CVI, focusing on molecular and genetic aspects of the disease. METHODS: The study depended on the recruitment of informative families, accurate determination of the phenotype of each family member, and blood sample for DNA extraction for genetic analysis. Each family member was invited to attend a vascular consultation. A genealogical tree for each recruited family was composed. Then, a peripheral blood sample for DNA extraction from each member of the recruited families was obtained for genetic evaluation. RESULTS: By the evaluation of genealogical trees, it was evident that CVI segregates, in all families studied, in an autosomal dominant mode with incomplete penetrance. In nine families studied, varicose veins were linked to the candidate marker D16S520 on chromosome 16q24, which may account for the linkage to FOXC2. CONCLUSION: In our study, in families with affected patients with the D16S520 marker, there was evidence of saphenofemoral junction reflux. The fact that there is linkage to a candidate marker for the FOXC2 gene suggests there is a functional variant within, or

in the vicinity of, which predisposes to varicose veins. Further studies are necessary to identify genes and mechanism so as to achieve better understanding of the genetic basis of CVI. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664280 [PubMed - indexed for MEDLINE] Related citations

6. Ann Vasc Surg. 2012 Jul;26(5):630-5. doi: 10.1016/j.avsg.2011.11.033. Vena cava filter practices of a regional vascular surgery society. Friedell ML, Nelson PR, Cheatham ML. Source Department of Surgical mark.friedell@tmcmed.org Abstract BACKGROUND: Vena cava filter (VCF) use in the United States has increased dramatically with prophylactic indications for placement and the availability of low-profile retrievable devices, which are overtaking the filter market. We surveyed the practice patterns of a large group of vascular surgeons from a regional vascular surgery society to see whether they mirrored current national trends. METHODS: A 17-question online VCF survey was offered to all members of the Southern Association of Vascular Surgery. The responses were analyzed using the (2) goodness of fit tests. RESULTS: Of the 276 members surveyed, 126 (46%) responded, with 118 (93%) indicating that they placed filters during their practice. Highly significant differences were identified with each question (at least P < 0.002). Regarding the inferior vena cava, the preferred permanent filters were the Greenfield (31%), the TrapEase (15%), the Vena Tech (5%), and a variety of retrievable devices (49%). Fifty percent of the respondents placed retrievable filters selectively; 26% always placed them; and 24% never did. Filters were placed for prophylactic indications <50% of the time by 63% of the respondents. Overall, retrievable filters (when not used as permanent filters) were removed <25% of Education, Orlando Health, Orlando, FL, USA.

the time by 64% of the respondents and <50% of the time by 78% of the respondents. The femoral vein was the preferred access site for 84% of the respondents. Major complications were few but included filter migration to the atrium (one), atrial perforation (one), abdominal pain requiring surgical filter removal (two), inferior vena cava thrombosis (12 vena cava thrombosis--4 due to TrapEase filters), strut fracture with embolization to heart or lungs (three Bard retrievable filters), and severe tilting precluding percutaneous retrieval and protection from pulmonary emboli (8 filters with severe tilt--7 of which were Bard). Of the respondents, 59% had never placed a superior vena cava filter, and 28% had placed five or fewer. CONCLUSIONS: Although VCF insertion overall appears safe, some complications are specific to biconical and certain retrievable filters. Given the low removal rate and lack of longterm experience with retrievable filters, routine use of these devices as permanent filters should be questioned. If used on a temporary basis, there should be a plan for filter removal at the time of implantation. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664279 [PubMed - indexed for MEDLINE] Related citations

7. Ann Vasc Surg. 2012 Jul;26(5):720-8. doi: 10.1016/j.avsg.2011.11.032. Epub 2012 Apr 26.

Anatomopathological and immunohistochemical explanted cryopreserved arteries.

study

of

Rendal-Vzquez ME, San Luis Verdes A, Pombo Otero J, Segura Iglesias R, Domenech Garca N, Andin Nez C. Source Complejo Hospitalario Universitario A Corua, Unidad de Criobiologa-Banco de Tejidos, La Corua, Espaa. Esther.Rendal.Vazquez@sergas.es Abstract BACKGROUND: The aim of the study was to analyze the mechanism of deterioration of implanted arteries. METHODS:

Eleven patients were included. Samples of vascular segments obtained from multiorgan donors and samples of the same vascular segments after explantation in the recipient were analyzed. Blood group, time of cold and warm ischemia, cause of death, time spent in the intensive care unit, time of storage of the cryopreserved grafts, and anatomopathological and immunohistochemical studies were analyzed using the preimplant samples obtained from the multiorgan donor. For samples obtained from the recipient, blood group, duration for which the tissue from the donor has been implanted, reason for graft explantation, and anatomopathological and immunohistochemical studies were analyzed. RESULTS: Histopathologically, the main finding has been the substitution of the muscular cap of the arterial wall by an intense fibrosis, in most of the cases, of a symmetrical nature. Besides this degeneration of myocytes, there is marked perivascular fibrosis and fibrointimal thickening also exists. The T lymphocytes suggest the importance of the immunological mechanism in the distortion of the architecture of the arteries. The atherosclerosis plays a less relevant role. CONCLUSIONS: Evidence of immune-mediated injury was found, and this mechanism seems to be responsible for the degenerative process in cryopreserved homografts. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22542146 [PubMed - indexed for MEDLINE] Related citations

8. Ann Vasc Surg. 2012 Jul;26(5):680-4. doi: 10.1016/j.avsg.2011.09.014. Epub 2012 Apr 24.

Complications of arteriovenous fistula for hemodialysis: an 8year study.

Fokou M, Teyang A, Ashuntantang G, Kaze F, Eyenga VC, Chichom Mefire A, Angwafo F 3rd. Source Department of Surgery, mfokou@yahoo.com Abstract BACKGROUND: Yaound General Hospital, Yaound, Cameroon.

To assess the frequency and characteristics of complications of arteriovenous fistula (AVF) and their effect on fistula outcome. METHODS: We retrospectively reviewed 628 AVFs constructed from November 2002 to October 2010 to record the complications and their management options. The association between age, sex, comorbidities (HIV, hypertension, and diabetes), fistula type, and complications was sought. RESULTS: Most patients were males (73.7%). The mean age was 45.3 years. Comorbidities seen included diabetes mellitus (22.12%), hypertension (83.12%), and HIV infection (9.87%). AVFs constructed were mainly radiocephalic (68%) and brachiocephalic (24.9%). The median follow-up period was 275 days. The cumulative patency rate was 76% and 51% at 1 year and 2 years, respectively. Altogether, 211 complications occurred in 16% of the AVFs. Among them, 36.96% were severe, 25.11% moderate, and 43.91% minor. With respect to the time of occurrence, 63.98% were late complications, 12.79% immediate, and 23.22% early. Aneurysms, failure to mature, and thrombosis were the most frequent complications occurring in 26.54%, 14.69%, and 12.79% of cases, respectively. The management options for the complications included the creation of a new access in 36.96%, a temporary catheter before a new AVF in 10.52%, and nonoperative management in 43.12%. We found no adverse effect of comorbid factors such as diabetes mellitus ((2) = 3.58, P > 0.05) or HIV-positive status ((2) = 0.64, P > 0.05) on the complication rate. CONCLUSION: This study shows an overall frequency of complications of 16%. These results show the potential for low complication rate of AVF in selected population. Copyright 2012. Published by Elsevier Inc. PMID: 22534263 [PubMed - indexed for MEDLINE] Related citations

9. Ann Vasc Surg. 2012 Jul;26(5):607-11. doi: 10.1016/j.avsg.2011.10.019. Epub 2012 Apr 18.

Success of endovenous saphenous and perforator ablation in patients with symptomatic venous insufficiency receiving longterm warfarin therapy.
Gabriel V, Jimenez JC, Alktaifi A, Lawrence PF, O'Connell J, Derubertis BG, Rigberg DA, Gelabert HA.

Source Division of Vascular Surgery, UCLA Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine, Los Angeles, CA 90095, USA. Abstract BACKGROUND: Endovenous ablation of great (GSV) and short saphenous vein (SSV) reflux has become the initial procedure for most patients with symptomatic venous insufficiency, and perforator ablation is increasingly used to assist in healing venous ulceration. Many patients have comorbid conditions, which require long-term anticoagulation with warfarin; however, the impact of a long-term anticoagulation therapy on endovenous ablation procedures is not understood. This study aims to determine the effects of chronic anticoagulation on the outcomes of endovenous ablation procedures in patients with chronic venous insufficiency (CVI). METHODS: Consecutive patients undergoing endovenous ablation for to Clinical severity (CEAP) class 2 through 6 CVI between January 1, 2005 and May 1, 2011 were evaluated; 781 patients with chronic venous reflux underwent 1,180 endovenous ablation procedures. We identified 45 patients receiving long-term anticoagulation therapy who underwent 71 endovenous ablation procedures, including 37 GSVs, 12 SSVs, and 22 perforator vein procedures. All patients underwent wound examination and duplex ultrasonography within 48 to 72 hours. Outcomes evaluated included closure rate and postoperative complications. RESULTS: The mean age of the patients was 69.7 13 years. Most patients treated presented with active venous ulceration (59% CEAP 6). Indications for anticoagulation included atrial fibrillation (n = 9, 20%), previous deep venous thrombosis (n = 16, 36%), hypercoagulable state (n = 9, 20%), prosthetic valve (n = 2, 4%), and others (n = 9, 20%). All patients receiving warfarin therapy (100%) underwent a postprocedure ultrasonography, which confirmed the successful closure of the GSVs and SSVs; successful initial perforator closure was achieved in 59% of patients (13/22). Repeat perforator ablation yielded a closure rate of 77%. Compared with a matched cohort group of 35 patients (61 perforators) undergoing perforator ablation without anticoagulation, treated during the same period, there was no significant difference in the rates of successful closure between the groups. No patients developed postoperative deep venous thrombosis or pulmonary embolus. No additional thrombotic complications were noted. Three patients (4.2%) developed a small hematoma after the procedure, which resolved with conservative treatment. No patients required postoperative hospital admission, and no postprocedure deaths occurred. CONCLUSIONS: Based on our protocol, patients with severe CVI who were receiving long-term warfarin therapy can be treated safely and effectively with endovenous radiofrequency ablation for incompetent GSVs, SSVs, and perforator veins. Long-term warfarin therapy did not have a significant effect on perforator closure rates compared with no anticoagulation.

Copyright 2012 Annals of Vascular Surgery Inc. All rights reserved. PMID: 22516240 [PubMed - indexed for MEDLINE] Related citations

10. Ann Vasc Surg. 2012 Jul;26(5):700-6. doi: 10.1016/j.avsg.2011.10.020. Epub 2012 Apr 12.

A diabetic foot service established by a department of vascular surgery: an observational study.

Williams DT, Majeed MU, Shingler G, Akbar MJ, Adamson DG, Whitaker CJ. Source Department of Vascular Surgery, Ysbyty Gwynedd Hospital, Bangor, Gwynedd, UK. dean.williams2@wales.nhs.uk Abstract BACKGROUND: The mechanism by which the multidisciplinary approach to diabetic foot disease reduces amputation rates is unclear. Ischemia, sepsis, and necrosis represent aspects of severe diabetic foot disease amenable to intervention. In 2006, a vascular unit introduced a rapid access service for severe foot disease, augmenting the established community provision. This study aimed to determine whether concurrent changes in amputation rates were observed, and to identify areas that may have influenced outcomes. METHODS: Unit data prospectively collected during 4 years for patients with lower-limb disease were compared with data retrieved over 2 years before the foot service. Outcome measurements were major amputations, foot surgery, vascular interventions, admissions, and length of stay. RESULTS: Major amputation rates associated with diabetes peaked in 2005 at 24.7/10,000 vs. 1.07/10,000 in 2009; (relative risk = 0.043, 95% confidence interval = 0.006-0.322). The proportion of diabetic to nondiabetic amputations decreased; foot surgery rates also dropped (53.7/10,000 in 2006 vs. 7.5/10,000 in 2009). The number of open revascularization procedures decreased, but the rates of endovascular procedures remained generally constant. Hospital admission rates decreased after initially peaking, and the length of stay was unchanged (16 vs. 15.5 days in 2004 and 2009, respectively).

CONCLUSIONS: The integration of a vascular unit with community care has been associated with improved outcomes for patients with diabetic foot disease. Improvements were not related to the increased number of vascular procedures or hospitalizations, but did coincide with a greater proportion of patients attending the foot unit. The referral of patients to the unit facilitates the rapid management of severe disease, reducing delays deleterious to outcomes. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22503433 [PubMed - indexed for MEDLINE] Related citations

11. Ann Vasc Surg. 2012 Jul;26(5):620-9. doi: 10.1016/j.avsg.2011.02.051. Epub 2012 Mar 19.

Influence of aspirin therapy in the ulcer associated with chronic venous insufficiency.
del Ro Sol ML, Antonio J, Fajardo G, Vaquero Puerta C. Source Division of Vascular Surgery, University Hospital of Valladolid, Valladolid, Spain. mlriosol@yahoo.es Abstract BACKGROUND: To determine the effect of aspirin on ulcer healing rate in patients with chronic venous insufficiency, and to establish prognostic factors that influence ulcer evolution. METHODS: Between 2001 and 2005, 78 patients with ulcerated lesions of diameter >2 cm and associated with chronic venous insufficiency were evaluated in our hospital. Of these, 51 patients (22 men, 29 women) with mean age of 60 years (range: 36-86) were included in a prospective randomized trial with a parallel control group. The treatment group received 300 mg of aspirin and the control group received no drug treatment; in both groups, healing was associated with standard compression therapy. During followup, held weekly in a blinded fashion, there was ulcer healing as well as cases of recurrence. Results were analyzed by intention-to-treat approach. Cure rate was estimated using Kaplan-Meier survival analysis, and the influence of prognostic factors was analyzed by applying the Cox proportional hazards model.

RESULTS: In the presence of gradual compression therapy, healing occurred more rapidly in patients receiving aspirin versus the control subjects (12 weeks in the treated group vs. 22 weeks in the control group), with a 46% reduction in healing time. The main prognostic factor was estimated initial area of injury (P = 0.032). Age, sex, systemic therapy, and infection showed little relevance to evolution. CONCLUSIONS: The administration of aspirin daily dose of 300 mg shortens the healing time of ulcerated lesions in the chronic venous insufficiency (CVI). The main prognostic factor for healing of venous ulcerated lesions is the initial surface area of the ulcer. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22437068 [PubMed - indexed for MEDLINE] Related citations

12. Ann Vasc Surg. 2012 Jul;26(5):707-14. doi: 10.1016/j.avsg.2011.11.011. Epub 2012 Feb 10.

Crossover femoropopliteal bypass: single graft or double grafts.

Gokalp O, Yurekli I, Yilik L, Bayrak S, Yasa H, Sahin A, Kestelli M, Yetkin U, Gurbuz A. Source Department of Cardiovascular Surgery, Izmir Ataturk Education and Research Hospital, Izmir, Turkey. Abstract BACKGROUND: Both single-graft crossover femoropopliteal (COFP) bypass and crossover femorofemoral plus femoropopliteal bypasses using double grafts may be performed for patients with a medical history of abdominal vascular operations or comorbidity, thereby ineligible for retroperitoneal or transperitoneal approaches. In this study, these two methods were compared. METHODS: A total of 15 patients who were operated on between February 2002 and March 2010 were included and studied retrospectively. Eight of them underwent crossover

femorofemoral bypass plus femoropopliteal bypass with double grafts (group 1), whereas the rest seven underwent single-graft COFP bypass (group 2). All the patients were included either in class 3 or class 4 according to Fontaine classification. Preoperative arterial Doppler ultrasound and arteriography were obtained from every patient. Pre- and postoperative ankle-brachial indices were measured. Postoperative clinical parameters were obtained from medical records. RESULTS: Median primary and secondary patency rates were 40.5 (7-105) months and 58 (7-105) months in group 1, respectively. In group 2, these rates were 42 (2-84) months and 44 (11-84) months, respectively. Two patients in group 1 and one patient in group 2 were amputated. There were no significant differences between both groups in terms of duration of hospital stay, duration of intensive care unit stay, and units of packed red blood cells transfused (P > 0.05). In addition, postoperative ankle-brachial indices were significantly improved in both groups (P < 0.05). COFP bypass can be performed for limb salvage in cases with critical limb ischemia with a medical history of previous vascular surgery or comorbidity, thereby ineligible for aortic reconstruction. CONCLUSION: This procedure may also be performed as continuous COFP bypass using a single graft. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22325924 [PubMed - indexed for MEDLINE] Related citations

13. Ann Vasc Surg. 2012 Jul;26(5):655-64. doi: 10.1016/j.avsg.2011.11.010. Epub 2012 Feb 8.

A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center.
Franz RW, Skytta CK, Shah KJ, Hartman JF, Wright ML. Source The Vascular and Vein Center, Grant Medical Center, Columbus, OH, USA. rfranz2@ohiohealth.com Abstract BACKGROUND:

Upper-extremity arterial injuries are relatively uncommon, but they may significantly impact patient outcome. Management of these injuries was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS: Upper-extremity trauma patients presenting with arterial injury between January 2005 and July 2010 were included in this retrospective review. Descriptive statistics were used to describe demographic, injury, treatment, and outcome data. These variables also were compared between blunt and penetrating arterial injuries and between proximal and distal arterial injuries. RESULTS: During a 5.6-year period, 135 patients with 159 upper-extremity arterial injuries were admitted, yielding an incidence of 0.74% among trauma admissions. The majority of patients (78.5%) suffered concomitant upper-extremity injuries. The most common injury mechanism was laceration by glass (26.4%). Arterial injuries were categorized into 116 penetrating (73.0%) and 43 blunt (27.0%) mechanisms. Arterial distribution involved was as follows: 13 axillary (8.2%), 40 brachial (25.2%), 52 radial (32.7%), 51 ulnar (32.1%), and 3 other (1.9%). The types of arterial injuries were as follows: 69 transection (43.4%), 68 laceration (42.8%), 16 occlusion (10.1%), 3 avulsion (1.9%), and 3 entrapment (1.9%). One patient (0.7%) required a primary above-elbow amputation. The majority of injuries (96.8%) receiving vascular management underwent surgical intervention--76 primary repair (49.7%), 41 ligation (26.8%), 31 bypass (20.3%), and 5 endovascular (3.3%). Conservative treatment was the primary strategy for five arterial injuries (3.3%). Of the patients receiving vascular intervention, three (2.2%) required major and three (2.2%) required minor amputations during hospitalization and no patients expired. CONCLUSION: The current multidisciplinary team management approach with prompt surgical management resulted in successful outcomes after upper-extremity arterial injuries. No outcome differences between penetrating and blunt or between proximal and distal arterial injuries were calculated. This management approach will continue to be used. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22321482 [PubMed - indexed for MEDLINE] Related citations

14. Ann Vasc Surg. 2012 Jul;26(5):612-9. doi: 10.1016/j.avsg.2011.10.013. Epub 2012 Feb 8.

Benefit of a single dose of preoperative antibiotic on surgical site infection in varicose vein surgery.
Singh R, Mesh CL, Aryaie A, Dwivedi AK, Marsden B, Shukla R, Annenberg AJ, Zenni GC. Source Department of Surgery, Mercy Jewish Hospital, Cincinnati, OH, USA. Abstract BACKGROUND: Ligation and division of the saphenofemoral junction (L/D SFJ) can protect against the danger of venous thromboembolism (VTE) associated with greater saphenous vein (GSV) radiofrequency ablation (RFA). Although this procedure is regarded as clean from an infection standpoint, surgical site infection (SSI) can offset its thromboembolic benefit. We questioned whether SSI associated with L/D SFJ could be minimized by a single preoperative dose of antibiotic. METHODS: A retrospective cohort study was performed on 902 ambulatory surgery patients who underwent 953 consecutive RFAs of the GSV in combination with L/D SFJ. A single dose of preoperative antibiotic was administered 1 hour before incision to some patients (n = 449 extremities), with all other patients receiving no antibiotic (n = 504). Primary outcome measure was SSI categorized based on type of therapy required (1: oral antibiotic, 2: hospitalization for intravenous antibiotic and/or wound debridement), with a secondary outcome measure of VTE. RESULTS: VTE occurred in 10 patients (1%) and included three pulmonary emboli. The majority of VTE were calf deep vein thromboses (n = 7). SSI developed in 78 patients (8.2%) with groin, thigh, and calf distributions of 47%, 8%, and 45%, respectively. All category 2 infections (n = 8, 10%) occurred in control subjects, and the majority were located in the groin. Body mass index significantly increased risk for both overall (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.05-1.14, P < 0.0001) and groin (OR: 1.08, 95% CI: 1.02-1.14, P = 0.01) SSI as well as VTE (OR: 1.17, 95% CI: 1.08-1.30, P = 0.003). Diabetes was a significant risk for groin SSI (OR: 5.13, 95% CI: 1.44-18.26, P = 0.01). Antibiotic was associated with a significantly reduced risk for both overall (OR: 0.54, 95% CI: 0.37-0.89, P = 0.02) and groin (OR: 0.34, 95% CI: 0.16-0.73, P = 0.01) SSI. Furthermore, prophylaxis eliminated category 2 infections (P = 0.008) and was associated with a significantly lower risk of VTE (OR: 0.11, 95% CI: 0.01-0.85, P = 0.01). Although SSI was noted more commonly in extremities with thromboembolic complications (20% [n = 2] vs. 8.1% [n = 76] in those without), this trend was not significant and could not account for the antibiotic effect on VTE. CONCLUSIONS: L/D SFJ combined with RFA of the GSV, when treated as a clean procedure and not prophylaxed with antibiotic, carries a significant risk of SSI. While diabetes and high

body mass index are patient-associated SSI risk factors, a single dose of preoperative antibiotic significantly reduces the rate of all infection, eliminates the danger of serious infection, and is associated with minimal VTE. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22321480 [PubMed - indexed for MEDLINE] Related citations

15. Ann Vasc Surg. 2012 Jul;26(5):685-92. doi: 10.1016/j.avsg.2011.11.009. Epub 2012 Feb 4.

Vascular surgery collaboration during pancreaticoduodenectomy with vascular reconstruction.

Turley RS, Peterson K, Barbas AS, Ceppa EP, Paulson EK, Blazer DG 3rd, Clary BM, Pappas TN, Tyler DS, McCann RL, White RR. Source Department of Surgery, Duke University, Durham, NC 27710, USA. Abstract BACKGROUND: Once thought to have unresectable disease, pancreatic cancer patients with portal venous involvement are now reported to have comparable survival after pancreaticoduodenectomy (PD) with vascular reconstruction (VR) as compared with patients without vascular involvement. We hypothesize that a multidisciplinary approach involving a vascular surgeon will minimize morbidity and improve patency of VRs. METHODS: We identified 204 patients who underwent PD for pancreatic adenocarcinoma from 1997 to 2008. Patients who underwent PD with VR (N = 42) were compared with those who underwent standard PD (N = 162). VRs were performed by a vascular surgeon and involved primary repair (N = 8), vein patch (N = 25), or interposition grafting (N = 9) with femoral or other venous conduit. RESULTS: Patients undergoing PD with VR had larger tumors (3.0 cm vs. 2.5 cm, P < 0.01) but did not have different rates of tumor-free margins (73% vs. 72%, P = 0.84) or lymph nodes metastases (50% vs. 38%, P = 0.14). The VR group had higher median blood

loss (875 mL vs. 550 mL, P = 0<0.01), but no differences in mortality, complication rates, length of stay, or readmission rates were found in a median follow-up of 29 months. Overall survival rates were similar. Predictors of mortality on multivariate analysis included increasing histological grade (P = 0.01), positive lymph nodes (P = 0.01), and increasing tumor size (P = 0.01), but not VR (P = 0.28). When evaluated by computed tomography scans within 6 months postoperatively, 97% of reconstructions remained patent. CONCLUSIONS: The need for VR is not a contraindication to potentially curative resection in patients with pancreatic adenocarcinoma. Assistance of a vascular surgeon during VR may allow moderate-volume centers to achieve outcomes comparable with high-volume centers. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22305864 [PubMed - indexed for MEDLINE] Related citations

16. Ann Vasc Surg. 2012 Jul;26(5):747-53. doi: 10.1016/j.avsg.2011.11.004. Epub 2012 Jan 31.

Dialysis access.
Stone PA, Mousa AY, Campbell JE, AbuRahma AF. Source West Virginia University, Charleston, WV 25304, USA. pstone0627@yahoo.com Abstract Although hemodialysis access procedures are considered the most common vascular procedures performed by either general or vascular surgeons, there is a paucity of level-one evidence in the literature. Randomized controlled trials are limited, and most of these studies have small sample sizes compared with other areas of vascular surgery, that is, carotid or aneurysm studies. We summarize the results of the world's literature for arteriovenous access in table format as a tool for those specialists managing patients with arteriovenous access procedures. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22296951

[PubMed - indexed for MEDLINE] Related citations

17. Ann Vasc Surg. 2012 Jul;26(5):649-54. doi: 10.1016/j.avsg.2011.10.009. Epub 2012 Jan 30.

Temporal artery biopsy is not required in all cases of suspected giant cell arteritis.
Quinn EM, Kearney DE, Kelly J, Keohane C, Redmond HP. Source Department of Academic Surgery, Cork University Hospital, Wilton, Cork, Ireland. edelquinn@rcsi.ie Abstract BACKGROUND: Temporal artery biopsy (TAB) is performed during the diagnostic workup for giant cell arteritis (GCA), a vasculitis with the potential to cause irreversible blindness or stroke. However, treatment is often started on clinical grounds, and TAB result frequently does not influence patient management. The aim of this study was to assess the need for TAB in cases of suspected GCA. METHODS: We performed a retrospective review of 185 TABs performed in our institution from 1990 to 2010. Patients were identified through the Hospital In-Patient Enquiry database and theater records. Clinical findings, erythrocyte sedimentation rate, steroid treatment preoperatively, American College of Rheumatology (ACR) criteria for GCA score, biopsy result, and follow-up were recorded. RESULTS: Fifty-eight (31.4%) biopsies were positive for GCA. Presence of jaw claudication (P = 0.001), abnormal fundoscopy (P = 0.001), and raised erythrocyte sedimentation rate (P = 0.001) were significantly associated with GCA. The strongest association with positive biopsy was seen with the prebiopsy ACR score (P < 0.001). Twenty-four (13.7%) patients had undergone biopsy, despite no potential for meeting ACR criteria preoperatively. None of these were positive. Overall, 29 (16.4%) patients had management altered by TAB result. CONCLUSIONS: Our results confirm that TAB does not affect management in the majority of patients with suspected GCA. We conclude that TAB has benefit only for patients who score 2 or 3 on the ACR criteria for GCA without biopsy.

Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22285348 [PubMed - indexed for MEDLINE] Related citations

18. Ann Vasc Surg. 2012 Jul;26(5):674-9. doi: 10.1016/j.avsg.2011.07.019. Epub 2012 Jan 27.

Patients characteristics and outcome of 518 arteriovenous fistulas for hemodialysis in a sub-Saharan African setting.
Fokou M, Ashuntantang G, Teyang A, Kaze F, Chichom Mefire A, Halle MP, Angwafo F 3rd, Takongmo S, Sandmann W. Source Department of Surgery, mfokou@yahoo.com Abstract BACKGROUND: To present the particular aspects of arteriovenous fistula (AVF) for hemodialysis in subSaharan Africa in terms of patients' characteristics, patency and complication rates, as well as factors influencing them. METHODS: From November 2002 to November 2009, 518 fistulas were constructed on adults. Demographic data, patency, and complications were analyzed. The association between age, sex, and comorbidities (HIV, hypertension, diabetes) on one hand and complications as well as AVF patency on the other was sought. RESULTS: Males represented 73.7% of the patient population, and the mean age of the population was 45.3 years. As far as etiologies of end-stage renal disease (ESRD) and comorbidities are concerned, chronic glomerulonephritis was the leading cause of ESRD (134; 25.9%), followed by hypertension (22.3%), although prevalent in 83.2% of patients, and diabetes (20.1%), although prevalent in 22.2%. No cause for the ESRD could be identified in 89 patients (17.2%). Only 20.64% had AVF as the initial vascular access. The main types of AVF constructed were radiocephalic (68%) and brachiocephalic (24.9%). The median follow-up period was 275 days. The cumulative patency rate at 1 year and 2 years was 76% and 51%, respectively. Altogether, 188 complications occurred in 16% of the AVFs. Aneurysms, failure to mature, and Yaound General Hospital, Yaounde, Cameroon.

thrombosis were the most frequent complications occurring in 27.65%, 14.89%, and 10.63% of cases, respectively. The management options for the complications included the creation of a new access for 63 complications (33.51%) and nonoperative management in 44.14% of the cases. We found no adverse effect of comorbid factors like diabetes mellitus ((2) = 3.58, P > 0.05) and HIV-positive status ((2) = 0.64, P > 0.05) on the complications rate. CONCLUSION: According to our patients' characteristics, there is a possibility of constructing AVF on nearly every hemodialysis patient with a good outcome. Copyright 2012. Published by Elsevier Inc. PMID: 22284777 [PubMed - indexed for MEDLINE] Related citations

19. Ann Vasc Surg. 2012 Jul;26(5):643-8. doi: 10.1016/j.avsg.2011.08.016. Epub 2012 Jan 23.

Treatment of arteriovenous malformations involving the hand.

Park UJ, Do YS, Park KB, Park HS, Kim YW, Lee BB, Kim DI. Source Vascular Malformation Clinic, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Abstract BACKGROUND: Hand arteriovenous malformations (AVMs) are difficult to treat because of the necessity to maintain function and the high complication rate of treatment. The purpose of this study was to review the treatment of hand AVMs with embolo/sclerotherapy and the surgical procedures at a single institute. MATERIAL AND METHODS: We retrospectively reviewed the medical records and identified the patients who were referred to the vascular division owing to hand AVMs between 1995 and 2009. The lesions were classified according to their affected areas. The treatments used at the clinic included conservative treatment, amputation, and embolo/sclerotherapy. We investigated the clinical data and assessed the treatment results. RESULTS:

Sixty-four patients were involved in this study. The median follow-up duration was 26.9 months (range: 3.5-141.8 months). The median age of the patients was 31.5 years (range: 0.3-75.0 years). All of the lesions were of the extratruncal (ET) form, and 37 cases (57.8%) were of the infiltrating type. Sixteen patients were treated conservatively. Primary amputation was performed in seven cases with previous complications such as ulcer, bleeding, or functional limitations. Embolo/sclerotherapy with ethanol was performed in 41 patients. Sixteen (39.0%) of them showed clinical improvement. The treatment of 20 (48.8%) of the 41 patients was interrupted owing to a variety of complications, and 2 (4.9%) of these patients failed with embolo/sclerotherapy. Skin necrosis was the major complication, and this occurred in 17 patients treated with embolo/sclerotherapy--14 of these cases were small and the skin necrosis healed with conservative treatment; 1 patient had autoamputation owing to necrosis; and 2 patients underwent amputation surgery owing to gangrene. The risk for skin necrosis was higher for the AVMs that involved the subcutaneous layer and the AVMs that extended diffusely (P = 0.021, P = 0.011). Seven neuropathic complications developed after embolo/sclerotherapy, and all of them were transient. CONCLUSIONS: The symptoms and characteristics of the lesions are important factors in devising a treatment plan for AVMs. AVM treatment, and especially embolo/sclerotherapy, is a long-term prospect, and it carries a potential risk for serious complications. After every treatment, the lesions must be reevaluated and new treatment plans must be made by the members of a multidisciplinary team. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22266239 [PubMed - indexed for MEDLINE] Related citations

20. Ann Vasc Surg. 2012 Jul;26(5):739-46. doi: 10.1016/j.avsg.2011.06.011. Epub 2011 Dec 22.

Paradoxical pulmonary embolism with spontaneous aortocaval fistula.

De Rango P, Parlani G, Cieri E, Verzini F, Isernia G, Silvestri V, Cao P. Source Unit of Vascular and Endovascular Surgery, Hospital S. M. Misericordia, University of Perugia, Perugia, Italy. pderango@unipg.it Abstract BACKGROUND:

Paradoxical pulmonary embolisms are uncommon emergencies and can occur as a consequence of an aortocaval fistula due to unrecognized dislodgement of thrombus from aortic sac into pulmonary circulation. This study reviewed current literature and therapeutic options in this emergency condition requiring prompt management and repair. METHODS: Literature was systematically searched for paradoxical pulmonary embolism associated with aortocaval rupture. RESULTS: Eight published cases were identified. However, many other paradoxical pulmonary emboli could have remained undiagnosed due to challenging clinical presentation. Symptoms of high-output cardiac failure and respiratory distress in the presence of large aortoiliac aneurysm and venous hypertension are findings of a possible major abdominal arteriovenous fistula with paradoxical pulmonary embolism. Successful treatment depends on prevention of new embolism and proper management of perioperative hemodynamics and massive bleeding during fistula repair. Endovascular procedures have been recently used as useful tools in this field. Cava filter placement may be a first step to prevent further thrombus dislodgements during aortocaval repair. Immediate subsequent aortic stent-grafting can allow repair of aortocaval communication and exclusion of the abdominal aortic aneurysm from circulation with successful reversal of altered hemodynamic features. However, experience (especially in the long-term) is limited. CONCLUSIONS: Paradoxical pulmonary embolism from aortocaval fistula represents an extremely rare but true clinical emergency with high fatality rate. Recent advances in diagnostic technology and endovascular techniques can substantially improve outcomes of the disease. Clinical competence in early detection and diagnosis is essential for appropriate emergent management. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22197523 [PubMed - indexed for MEDLINE] Related citations

Ann Vasc Surg 2012; 26(5) Case Reports

1. Ann Vasc Surg. 2012 Jul;26(5):733.e9-12. doi: 10.1016/j.avsg.2011.10.024.

Endovascular central venous stenosis treatment ended with superior vena cava perforation, pericardial tamponade, and exitus.
Siani A, Marcucci G, Accrocca F, Antonelli R, Mounayergi F, Rosati MS, Gabrielli R. Source Department of Vascular Surgery, ASL-RMF San Paolo Hospital Civitavecchia, Rome, Italy. Abstract Venous hypertension and outflow stenosis of arteriovenous hemodialysis access managed using endovascular procedures usually present a high technical success rate, with few complications. We reported a rare and fatal complication of superior vena cava perforation with pericardial tamponade 3 months after subclavian vein stenting. Interventional recanalization with stenting for the management of superior vena cava syndrome or central vein stenosis is a safe procedure with a low complication rate. Stent misplacement, reocclusion, migration, or access-related complications appear to occur most frequently. Copyright 2012 Annals of Vascular Surgery Inc. All rights reserved. PMID: 22664297 [PubMed - indexed for MEDLINE] Related citations

2. Ann Vasc Surg. 2012 Jul;26(5):733.e5-7. doi: 10.1016/j.avsg.2011.10.023.

Aneurysm of the superior labial artery.

Seidel AC, Rossetti LP, Mangolim AS, Gomes JR, de Almeida Rollo H. Source Department of Angiology and Vascular Surgery, Medical School of Universidade Estadual de Maring, Maring, Paran, Brazil.

Abstract This is a case report of a true and dissecting aneurysm of the superior labial artery in a 51-year-old patient without risk factors for vascular pathology. The patient complained of swelling of the upper lip, mostly on the left side. A Doppler ultrasonography was used in the diagnosis. The definitive treatment was surgical resection, and the histopathological analysis confirmed the diagnosis. The progress of the patient was satisfactory, leaving a slight change in sensitivity in the area. This seems to be the first reported case of true and dissecting aneurysm of the superior labial artery in the medical literature. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664296 [PubMed - indexed for MEDLINE] Related citations

3. Ann Vasc Surg. 2012 Jul;26(5):733.e1-4. doi: 10.1016/j.avsg.2011.08.028.

Endovascular treatment of an iatrogenic perforation of the internal iliac vein.

Willaert W, Van Herzeele I, Ceelen W, Van De Putte D, Vermassen F, Pattyn P. Source Department of Surgery, wouterwillaert@yahoo.co.uk Abstract We describe the case of a 48-year-old woman who developed a pelvic abscess after extensive surgery for recurrent ovarian cancer. While draining the abscess, a massive venous bleeding occurred. The bleeding was controlled by introducing a Foley catheter transrectally, occluding the perforated internal iliac vein. However, the catheter was positioned unintentionally in the inferior vena cava, causing hemodynamic instability. The iatrogenic perforation of the internal iliac vein was managed successfully with an endovascular approach using thrombin in combination with balloon-induced thrombosis. If iatrogenic venous bleeding occurs and the placement of a stent is precluded, balloon-induced thrombosis in combination with thrombin injection can be used successfully. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664295 Ghent University Hospital, Ghent, Belgium.

[PubMed - indexed for MEDLINE] Related citations

4. Ann Vasc Surg. 2012 Jul;26(5):732.e7-11. doi: 10.1016/j.avsg.2011.08.029.

Incapacitating pelvic congestion syndrome in a patient with a history of May-Thurner syndrome and left ovarian vein embolization.
Rastogi N, Kabutey NK, Kim D. Source Division of Interventional Radiology, Department of Radiology, Boston Medical Center, Boston, MA 02118, USA. neerajrastogi@hotmail.com Abstract BACKGROUND: The aim of this article is to report a rare case of unresolved incapacitating pelvic congestion syndrome (PCS) in a patient with a history of May-Thurner syndrome previously treated with stenting and left ovarian vein embolization. Additionally, this article highlights the role of pelvic venography in patients with PCS and reviews the coexistence. METHODS: A 32-year-old woman was referred to us for the evaluation of recurrent pelvic pain and dyspareunia requiring analgesics. Initially, she developed left lower-extremity deep vein thrombosis a few months after her first pregnancy. On further workup, she was diagnosed with May-Thurner syndrome and underwent left common iliac and left external iliac vein stenting. Furthermore, left ovarian vein coil embolization was performed for symptoms suggesting PCS at the same outside facility. The patient was referred to us for persistent pelvic pain approximately 1 year after she underwent left ovarian vein coil embolization. A diagnosis of incompletely resolved PCS was considered. RESULTS: Iliocaval venogram demonstrated patent left common iliac and external iliac venous stents in situ. Subsequent right ovarian venogram revealed a patent, but grossly dilated, right ovarian vein with retrograde flow and cross-pelvic collaterals confirming grade III PCS. Right ovarian vein coil embolization was performed, with excellent patient outcome. CONCLUSION:

In the setting of a combined diagnosis of PCS and May-Thurner syndrome, persistent incapacitating PCS after initial iliac stenting should be followed with a complete pelvic venous evaluation including ovarian and left renal venography to rule out residual pelvic congestion secondary to any coexisting ovarian vein incompetencies or nutcracker syndrome. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664294 [PubMed - indexed for MEDLINE] Related citations

5. Ann Vasc Surg. 2012 Jul;26(5):732.e1-6. doi: 10.1016/j.avsg.2011.08.030.

Acute expansion of a hospital-acquired methicillin-resistant Staphylococcus aureus-infected abdominal aortic aneurysm.

Reslan OM, Ebaugh JL, Gupta N, Brecher SM, Itani KM, Raffetto JD. Source Department of Surgery, VA Boston HCS, West Roxbury, MA 02132, USA. Abstract Infected aortic aneurysms (IAAs) are rare but can have devastating outcomes, particularly if diagnosis and treatment are delayed. The incidence of IAA is between 0.65% and 2% of all aortic aneurysms. The disease has a poor prognosis because these aneurysms have an increased tendency to grow rapidly and to rupture, and patients often have severe comorbidities and coexisting sepsis. Typical microorganisms associated with IAA are Salmonella, Streptococci, and Staphylococcus aureus. Methicillin-resistant Staphylococcus aureus (MRSA) continues to emerge as a cause of serious infections, but its association with IAA is extremely rare. We present a rare case of infected abdominal aortic aneurysm caused by hospital-acquired (HA) MRSA. This case adds another presentation to the clinical spectrum of HA MRSA infections, and it highlights the problems encountered in the choice of the therapy of serious HA or health care-acquired infections in an era of increasing MRSA infections. We will discuss the clinical spectrum of HA MRSA infections as well as the problems encountered in the management of IAA, and will review the relevant literature. Published by Elsevier Inc. PMID: 22664293 [PubMed - indexed for MEDLINE] Related citations

6. Ann Vasc Surg. 2012 Jul;26(5):731.e9-13. doi: 10.1016/j.avsg.2011.10.021.

Stepwise revascularization by carotid endarterectomy after balloon angioplasty for symptomatic severe carotid artery stenosis.
Egashira Y, Yoshimura S, Yamada K, Enomoto Y, Asano T, Iwama T. Source Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan. egashi@gifu-u.ac.jp Abstract The authors report a novel stepwise carotid revascularization method to prevent perioperative complication. A 68-year-old man presented with left hemiparesis and dysarthria caused by severe stenosis of the right cervical internal carotid artery. According to the preoperative cerebral blood flow evaluation and plaque characterization, the patient was at risk for postoperative hyperperfusion and ischemic complications after carotid artery stenting. Initially, the patient underwent percutaneous angioplasty using an undersized balloon. Fifteen days later, the patient underwent a carotid endarterectomy. The surgical specimen obtained during the carotid endarterectomy showed the presence of typical vulnerable plaque. Of note was the complete preservation of the thin fibrous cap. The postoperative single-photon emission tomography images showed no signs of hyperperfusion, and the patient developed no neurological symptoms after each of the procedures. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664292 [PubMed - indexed for MEDLINE] Related citations

7. Ann Vasc Surg. 2012 Jul;26(5):731.e5-8. doi: 10.1016/j.avsg.2011.10.022.

Endovascular stent graft repair for a Salmonella-infected aneurysm of thoracic aorta.

Lao WF, Huang CH, Lin CH, Lu MJ, Hung CR. Source

Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Abstract Thoracic endovascular aneurysm repair using stent graft has been reported as a feasible and effective treatment for aortic aneurysm. However, its application for treating infected aortic aneurysms is still controversial and less reported. We report a 74-year-old male diabetic patient diagnosed with Salmonella-infected aortic aneurysm, who was successfully treated with endovascular stent graft repair followed by a 2month course of intravenous antibiotics and long-term oral antibiotic therapy. Sequential computed tomography scans demonstrated the shrinkage of the aneurysm and no evidence of relapse 11 months later. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664291 [PubMed - indexed for MEDLINE] Related citations

8. Ann Vasc Surg. 2012 Jul;26(5):731.e15-22. doi: 10.1016/j.avsg.2011.08.027.

Fenestrate what you can't snorkel?

Zayed MA, Chowdhury M, Casey K, Dalman RL, Lee JT. Source Department of Surgery, Stanford University Medical Center, Stanford, CA 94305, USA. Abstract BACKGROUND: Although challenging proximal necks have limited the utility of standard endovascular aneurysm repair (EVAR) devices, sophisticated endovascular techniques have evolved in recent years for the repair of juxtarenal abdominal aortic aneurysms (AAAs). Among these techniques, snorkel or chimney EVAR (sn-EVAR) and fenestrated EVAR (fEVAR) have emerged as options for repairing anatomic high-risk AAAs. Unfortunately, in the United States, except in the context of a clinical trial or physician-sponsored device exemption, limited long-term data exist on the treatment of juxta- and suprarenal AAAs with either sn-EVAR or f-EVAR. Owing to these limitations, comparison of these two techniques is challenging, and we sought to describe a case when one was favored over the other. METHODS AND RESULTS:

A 72-year-old man presented with an enlarging, asymptomatic, juxtarenal fusiform AAA (5.9 cm), a moderately enlarged right common iliac artery (2.8 cm), a history of oxygendependent chronic obstructive pulmonary disease, and a previous right nephrectomy. An initial sn-EVAR was attempted but was unsuccessful owing to the inability to deliver the "snorkel" covered stent via a brachial approach because of renal ostial stenosis and cephalad angulation of the patient's left renal artery. A subsequent f-EVAR approach was successfully used to repair the juxtarenal AAA while preserving adequate renal artery blood flow. Two-year postoperative follow-up demonstrated a stable endovascular repair without endoleaks, a shrinking aneurysm sac, and stable renal function. CONCLUSION: The sn-EVAR configuration in this case report was precluded by cephalad renal angulation, and the AAA was instead repaired using an f-EVAR approach, with good 2year follow-up outcomes. The sn-EVAR strategy requires downward pointing renal arteries in addition to adequate brachial/axillary artery access dimensions to facilitate successful repair. With improving techniques and technology for either approach, anatomic specifications and indications for these advanced EVAR strategies will need to be delineated. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664290 [PubMed - indexed for MEDLINE] Related citations

9. Ann Vasc Surg. 2012 Jul;26(5):731.e1-4. doi: 10.1016/j.avsg.2011.09.016.

Subclavian artery aneurysm in Marfan syndrome.

Morisaki K, Kobayashi M, Miyachi H, Maekawa T, Tamai H, Takahashi N, Watanabe Y, Morimae H, Ihara T, Kodama A, Narita H, Banno H, Yamamoto K, Komori K. Source Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan. Abstract We present a case of a left subclavian artery aneurysm in a 48-year-old man with Marfan syndrome. Aneurysms of the subclavian artery are rare in patients with Marfan syndrome. Resection of the aneurysm and interposition with a synthetic graft were performed through a supra- and infraclavicular incision, without resecting the clavicle. Histological findings were compatible with Marfan syndrome. In patients with Marfan

syndrome, regular follow-up is important because of the occurrence of peripheral aneurysms other than the aorta. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664289 [PubMed - indexed for MEDLINE] Related citations

10. Ann Vasc Surg. 2012 Jul;26(5):730.e7-11. doi: 10.1016/j.avsg.2011.11.037.

Pancreatitis-related abdominal aortic pseudoaneurysms treated with stent-grafts.

Stefaczyk L, Elgalal MT, Chrzstek J, Szubert W, Czeczotka J, Papiewski A, Piotr S. Source Department of Radiology, Medical University of Lodz, Lodz, Poland. Abstract Endovascular treatment of pseudoaneurysms that develop as a complication of pancreatitis is increasingly more common. A case of a pseudoaneurysm of the abdominal aorta initially treated by implantation of a straight aortic stent-graft is presented. In the 4 months after the procedure, chronic inflammation of the retroperitoneal space caused a further perforation on the posterior wall of the aorta in the area of the bifurcation, distal to the graft. Implantation of a bifurcated stent-graft was subsequently performed. The aneurysm was excluded, with the implant and peripheral arteries remaining patent. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664288 [PubMed - indexed for MEDLINE] Related citations

11. Ann Vasc Surg. 2012 Jul;26(5):730.e13-5. doi: 10.1016/j.avsg.2011.09.015.

Stent graft exclusion of a ruptured mycotic popliteal pseudoaneurysm complicating sternoclavicular joint infection.
Ghassani A, Delva JC, Berard X, Deglise S, Ducasse E, Midy D. Source Department of Vascular Surgery, University Hospital of Bordeaux, Bordeaux, France. afifghassani@gmail.com Abstract A mycotic pseudoaneurysm of the popliteal artery is usually a consequence of septic embolization and often a result of bacterial endocarditis. Conventional treatment is surgical and avoids the placement of foreign material in infected sites. Here we report our treatment of a 59-year-old man who presented with a rupture of a mycotic pseudoaneurysm of the popliteal artery due to septic embolism from sternoclavicular infectious arthritis. Radiological investigations are included. This is the first documented case of septic arthritis complicated by a rupture of a mycotic popliteal false aneurysm and treated using an endovascular procedure. Combining endovascular stent grafts with evacuation of the joint abscess and antibiotic therapy can offer a safe alternative for frail and unstable patients. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664287 [PubMed - indexed for MEDLINE] Related citations

12. Ann Vasc Surg. 2012 Jul;26(5):729.e11-5. doi: 10.1016/j.avsg.2011.11.042.

Fibular nerve injury after small saphenous vein surgery.

de Alvarenga Yoshida R, Yoshida WB, Sardenberg T, Sobreira ML, Rollo HA, Moura R. Source Department of Vascular and Endovascular Surgery, Botucatu School of Medicine, So Paulo State University, So Paulo, Brazil. ricardoyoshida@gmail.com Abstract Superficial nerve injuries are very common during varicose vein surgery. In contrast, deep nerve injuries are rare and reported especially when surgery involves the small saphenous vein (SSV). The deep motor nerves most commonly injured are the tibial

nerve and the peroneal nerve, which are directly or indirectly affected by extrinsic compression, stretching, or healing process involvement. In this report, two cases of common fibular nerve injury after SSV stripping are described, including treatment used and patient outcomes. Nerve damage mechanisms, anatomy, and prevention strategies are also discussed. In conclusion, fibular nerve damage may occur during SSV stripping. Preventive measures include careful preoperative ultrasonographic investigation of the anatomy of the vein, determining location of the saphenopopliteal joint, and careful dissection far from fibular nerve and restricted to the popliteal fossa. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664286 [PubMed - indexed for MEDLINE] Related citations

13. Ann Vasc Surg. 2012 Jul;26(5):729.e1-5. doi: 10.1016/j.avsg.2011.12.005.

Eagle syndrome revisited: cerebrovascular complications.

Todo T, Alexander M, Stokol C, Lyden P, Braunstein G, Gewertz B. Source Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. Abstract Cervical pain caused by the elongation of the styloid process (Eagle syndrome) is well known to otolaryngologists but is rarely considered by vascular surgeons. We report two patients with cerebrovascular symptoms of Eagle syndrome treated in our medical center in the past year. Case 1: an 80-year-old man with acromegaly presented with dizziness and syncope with neck rotation. The patient was noted to have bilateral elongated styloid processes impinging on the internal carotid arteries. After staged resections of the styloid processes through cervical approaches, the symptoms resolved completely. Case 2: a 57-year-old man presented with acute-onset left-sided neck pain radiating to his head immediately after a vigorous neck massage. Hospital course was complicated by a 15-minute transient ischemic attack resulting in aphasia. Angiography revealed bilateral dissections of his internal carotid arteries, with a dissecting aneurysm on the right. Both injuries were immediately adjacent to the bilateral elongated styloid processes. Despite immediate anticoagulation therapy, he experienced aphasia and right hemiparesis associated with an occlusion of his left carotid artery. He underwent emergent catheter thrombectomy and carotid stent placement, with near-complete resolution of his symptoms. Elongated styloid processes characteristic of Eagle syndrome can result in both temporary impingement and permanent injury to the extracranial carotid arteries. Although rare, Eagle syndrome should be considered in the differential diagnosis in patients with cerebrovascular symptoms, especially those induced by positional change.

Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22664285 [PubMed - indexed for MEDLINE] Related citations

14. Ann Vasc Surg. 2012 Jul;26(5):730.e1-5. doi: 10.1016/j.avsg.2011.11.030. Epub 2012 Apr 12.

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm.

Genovs-Gasc B, Torres-Blanco , Plaza-Martnez , Olmos-Snchez D, GmezPalons F, Ortiz-Monzn E. Source Servicio de Angiologa y Ciruga Vascular, Hospital Universitario Dr. Peset, Valencia, Espaa. genoves_bea@gva.es Abstract Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22503432 [PubMed - indexed for MEDLINE] Related citations

15. Ann Vasc Surg. 2012 Jul;26(5):729.e7-9. doi: 10.1016/j.avsg.2011.11.027. Epub 2012 Apr 10.

Surgical therapy of an asymptomatic primary popliteal venous aneurysm.

Lutz HJ, Sacuiu RD, Savolainen H. Source Department of Vascular and Endovascular Surgery, Verbundkrankenhaus Bernkastel/Wittlich, Wittlich, Germany. h.lutz@verbund-krankenhaus.de Abstract Primary popliteal venous aneurysm is a rare condition. To date, approximately 150 cases have been reported. In the present article, we report a 59-year-old man who presented with a swelling of the left popliteal fossa. Duplex ultrasound scan revealed a saccular aneurysm of the popliteal vein, with a diameter of 2.5 2.5 cm. The distal part of the popliteal vein was dilated in a fusiform configuration up to 2.0 cm on both sides. The diagnosis was confirmed using magnetic resonance imaging and ascending phlebography. There was no sign of venous thrombosis. Our patient presented without any previous clinical evidence of pulmonary emboli. Surgery was deemed indicated. A traditional tangential aneurysmectomy and lateral venorrhaphy of the distal fusiform part of the popliteal lesion was performed as well as resection of the saccular part using a dorsal approach. Surgery and recovery were uneventful. The patient presented for follow-up after 6 and 12 weeks without any complaints. Duplex ultrasound scanning and ascending phlebography (only once after 12 weeks) were performed, which confirmed patency. Copyright 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved. PMID: 22494930 [PubMed - indexed for MEDLINE] Related citations