Endovascular aneurysm repair reverses the increased titer and the inflammatory activity of interleukin-1α in the serum of patients with abdominal aortic aneurysm

OBJECTIVE

To examine serum cytokine/chemokine profiles before and 6 months after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) and to determine whether they correlate with serum inflammatory activity using an in vitro model of leukocyte recruitment.

METHODS

Serum IL-1-α, IL-1β, IL-4, IL-6, IL-8, IL-10, IFN-γ, IP-10, MCP-1, TNF-α, and TNF-β were measured using a cytometry-based immunoassay. To test patient serum for direct inflammatory activity, human endothelial cells (EC) were stimulated with 30% patient serum for 24 hours. To test patient serum for the ability to prime EC for inflammatory responses, EC were incubated with 30% patient serum for 24 hours, followed by stimulation with low-dose (5 U/mL) TNF for 4 hours. Under both regimens of stimulation, the degree of EC activation was assessed by assaying neutrophil recruitment in a flow-based model.

RESULTS

Only IL-1α (67.9 ± 10.4 pg/mL vs 41.9 ± 7.4 pg/mL) and IL-8 (51.5 ± 5.1 vs 32.6 ± 4.7 pg/mL) changed significantly after surgery. Patient serum alone was unable to activate EC. However, serum from both time points could prime EC responses to low-dose TNF. Thus, after priming with preoperative serum, EC stimulated with TNF could recruit 76.7 ± 12.0 neutrophils/mm(2) into the subendothelial cell space. Post-EVAR serum was significantly less effective (44.4 ± 10.2 neutrophils/mm(2)). This reduction in neutrophil recruitment correlated with reduced IL-1α in post-EVAR serum. The addition of a neutralizing antibody against IL-1α to pre-EVAR serum inhibited EC priming and neutrophil recruitment, strongly implying that this cytokine was the priming agent.

CONCLUSION

EVAR reduces serum IL-1α and its inflammatory activity in patient serum. IL-1α is, therefore, implicated in the molecular pathology of AAAs and may have potential as a clinically useful biomarker.

Epidemiology and aetiology of C4-6 disease

Although our understanding of chronic venous insufficiency (CVI) has improved, many important questions remain unanswered. Ensuring that patients are appropriately referred for specialist assessment and then receive evidence-based, cost-effective treatment continues to be challenging. The lifetime of risk of chronic venous ulceration (CVU) is around 1% with approximately 10% ulcers being open at any one time. The incidence skin changes disease is about 10 times greater (10%). However, many of the studies upon which these estimates are based are old and/or methodologically flawed. There is reason to believe that the incidence, prevalence and characteristics of CVI/CVU may have changed considerably over the last 10-20 years and that future change is likely. Further cross-sectional and longitudinal epidemiological studies are required to establish the size and nature of the health-care need going forward in developed and increasingly developing countries. CVI culminating CVU is primarily the result of sustained ambulatory venous hypertension, which in turn arises from superficial and/or deep venous reflux with or without deep vein obstruction. However, there are many other elements to this complex condition, for example, microvascular dysfunction; calf muscle pump efficiency; dermal inflammation; disordered fibroblast function and matrix production; failure of epithelialization; congenital and acquired thrombophilia; malnutrition, obesity and diet; and bacterial colonization. None of the currently available treatment modalities is entirely satisfactory and novel therapies based upon a clearer understanding of the disease at the psychological, genetic, mechanical, microvascular and microscopic level are required.

Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux

OBJECTIVE

To test the hypothesis that ultrasound-guided foam sclerotherapy (UGFS) is a safe and durable treatment for superficial venous reflux (SVR) associated with CEAP clinical grade 2-6 disease.

METHODS

This was an interrogation of a prospectively gathered computerized database.

RESULTS

Between March 23, 2004 and December 31, 2009, 977 patients (1252 legs) underwent UGFS for unilateral (702 legs) or bilateral (550 legs) SVR in association with CEAP clinical grade 2-3 (n = 868), 4 (n = 232), or 5/6 (n = 152) disease. The following reflux in 1417 venous segments was treated: primary great saphenous vein (GSV) (n = 745); recurrent GSV (n = 286), primary small saphenous vein (SSV) (n = 189), recurrent SSV (n = 50); primary anterior accessory saphenous vein (AASV) (n = 93); recurrent AASV (n = 46); vein of the popliteal fossa (VOPF) (n = 5), and Giacomini vein (GV) (n = 3). Three hundred forty-eight legs (27.8%) had undergone previous surgery. Three patients suffered post-UGFS deep vein thrombosis (DVT) and one a pulmonary embolus (PE), all within the first month (0.4% venous thrombo-embolic complication rate). Five patients (0.5%) had transient visual disturbance at the time of, or shortly after, treatment. No other neurologic or serious complications were reported. During a mean (range) follow-up of 28 (<1 to 68) months, 161 (12.9%) legs underwent a further session of UGFS for truncal VV at a mean (range) of 17 (<1 to 63) months following the first treatment. In 52 legs, retreatment was due to the development of new SVR and in 109 legs was for true recurrence (8.7% complete or partial recanalization rate leading to treatment). There was no significant difference in retreatment rates between UGFS for GSV and SSV reflux or between UGFS for primary or recurrent disease.

CONCLUSION

UGFS for CEAP 2-6 SVR is associated with a low complication and retreatment rate. However, as patients are at risk of developing recurrent and new SVR they should be kept under review. Further UGFS for new or recurrent disease is simple, safe, and effective.

Outcome in patients requiring renal replacement therapy after open surgical repair for ruptured abdominal aortic aneurysm

OBJECTIVE

To determine the relationship between postoperative renal replacement therapy (RRT) and patient survival after open surgical repair (OR) of ruptured abdominal aortic aneurysm (rAAA).

METHODS

A retrospective review of consecutive patients who underwent OR for rAAA repair between January 2002 and July 2008 was performed. Early (<30 days) and late (>30 days) outcomes were assessed.

RESULTS

A total of 94 patients (69 men; median [range] age 73.8 [56-89] years) underwent OR of rAAA (infrarenal = 78, juxtarenal = 15, and suprarenal = 1). In-hospital mortality rate was 40% and mean (range) length of intensive care unit (ICU) stay was 9.3 (0-56) days. A total of 23 (24%) patients required postoperative RRT. In-hospital mortality rate was significantly higher (RRT: 87% (20 of 23) vs no RRT: 18 of 71 (25%), P < .0001) and ICU stay significantly longer (RRT: mean (range) days; 14.8 (1-44) vs no RRT: 7.5 (0-56), P = .04) in the RRT patients. On multivariate analysis, RRT (P = .0053) and/or inotropic support (P = .0033) were independent risk factors for death within 30 days of the index procedure.

CONCLUSIONS

Renal replacement therapy following OR of rAAA is an independent risk factor for mortality.

Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial

OBJECTIVE

To compare a 'bypass-surgery-first' with a 'balloon-angioplasty-first' revascularisation strategy in patients with severe limb ischaemia (SLI) due to infrainguinal disease requiring immediate/early revascularisation.

DESIGN

A stratified randomised controlled trial. A Delphi consensus study of vascular surgeons' and interventional radiologists' views on SLI treatment was performed before the trial.

SETTING

Twenty-seven UK hospitals.

PARTICIPANTS

Patients presenting with SLI as the result of infrainguinal atherosclerosis and who, in the opinion of the responsible consultant vascular surgeon and interventional radiologist, required and were suitable for both surgery and angioplasty.

INTERVENTIONS

Patients were randomised to either 'bypass-surgery-first' or 'balloon-angioplasty-first' revascularisation strategies.

MAIN OUTCOME MEASURES

The primary end point was amputation-free survival (AFS); secondary end points were overall survival (OS), health-related quality of life (HRQoL) and cost-effective use of hospital resources.

RESULTS

AFS at 1 and 3 years was not significantly different for surgery and angioplasty. Interim analysis showed that surgery was associated with significantly lower immediate failure, higher 30-day morbidity and lower 12-month reintervention rates than angioplasty; 30-day mortality was similar. Beyond 2 years from randomisation, hazard ratios (HRs) were significantly reduced for both AFS (adjusted HR 0.37; 95% CI 0.17 to 0.77; p = 0.008) and OS (HR 0.34; 95% CI 0.17 to 0.71; p = 0.004) for surgery relative to angioplasty. By 2008 all but four patients had been followed for 3 years, some for over 7 years: 250 (56%) were dead, 168 (38%) were alive without amputation and 30 (7%) were alive with amputation. Considering the follow-up period as a whole, AFS and OS did not differ between treatments but for patients surviving beyond 2 years from randomisation, bypass was associated with reduced HRs for AFS (HR 0.85; 95% CI 0.50 to 1.07; p = 0.108) and OS (HR 0.61; 95% CI 0.50 to 0.75; p = 0.009), equating to an increase in restricted mean OS of 7.3 months (p = 0.02) and AFS of 5.9 months (p = 0.06) during the subsequent follow-up period. Vein bypasses and angioplasties performed better than prosthetic bypasses. HRQoL was non-significantly better in the surgery group; amputation was associated with a significant reduction in HRQoL. Over the first year, hospital costs for bypass were significantly higher (difference 5420 pounds; 95% CI 1547 pounds to 9294 pounds) than for angioplasty. However, by 3 and at 7 years the differences in cost between the two strategies were no longer significant. Patients randomised to surgery lived, on average, 29 days longer at an additional average cost of 2310 pounds. A 36-month perspective showed not significantly different mean quality-adjusted life times for angioplasty and surgery. The Delphi study revealed substantial disagreement between and among surgeons and radiologists on the appropriateness of bypass surgery or balloon angioplasty.

CONCLUSIONS

The findings of our study suggest that in patients with SLI due to infrainguinal disease the decision whether to perform bypass surgery or balloon angioplasty first appears to depend upon anticipated life expectancy. Patients expected to live less than 2 years should usually be offered balloon angioplasty first as it is associated with less morbidity and cost, and such patients are unlikely to enjoy the longer-term benefits of surgery. By contrast, those patients expected to live beyond 2 years should usually be offered bypass surgery first, especially where a vein is available as a conduit. Many patients who could not undergo a vein bypass would probably have been better served by a first attempt at balloon angioplasty than prosthetic bypass. The failure rate of angioplasty in SLI is high (c. 25%) and patients who underwent bypass after failed angioplasty fared significantly worse than those who underwent surgery as their first procedure. The interests of a significant proportion of BASIL patients may have been best served by primary amputation followed by high-quality rehabilitation. Further research is required to confirm or refute the BASIL findings and recommendations; validate the BASIL survival prediction model in a separate cohort of patients with SLI; examine the clinical and cost-effectiveness of new endovascular techniques and devices; and compare revascularisation with primary amputation and with best medical and nursing care in those SLI patients with the poorest survival prospects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45398889.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy

BACKGROUND

A 2005 interim analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI; rest pain, ulceration, gangrene) due to infrainguinal disease, bypass surgery (BSX)-first and balloon angioplasty (BAP)-first revascularization strategies led to similar short-term clinical outcomes, although BSX was about one-third more expensive and morbidity was higher. We have monitored patients for a further 2.5 years and now report a final intention-to-treat (ITT) analysis of amputation-free survival (AFS) and overall survival (OS).

METHODS

Of 452 enrolled patients in 27 United Kingdom hospitals, 228 were randomized to a BSX-first and 224 to a BAP-first revascularization strategy. All patients were monitored for 3 years and more than half for >5 years.

RESULTS

At the end of follow-up, 250 patients were dead (56%), 168 (38%) were alive without amputation, and 30 (7%) were alive with amputation. Four were lost to follow-up. AFS and OS did not differ between randomized treatments during the follow-up. For those patients surviving 2 years from randomization, however, BSX-first revascularization was associated with a reduced hazard ratio (HR) for subsequent AFS of 0.85 (95% confidence interval [CI], 0.5-1.07; P = .108) and for subsequent OS of 0.61 (95% CI, 0.50-0.75; P = .009) in an adjusted, time-dependent Cox proportional hazards model. For those patients who survived for 2 years after randomization, initial randomization to a BSX-first revascularization strategy was associated with an increase in subsequent restricted mean overall survival of 7.3 months (95% CI, 1.2-13.4 months, P = .02) and an increase in restricted mean AFS of 5.9 months (95% CI, 0.2-12.0 months, P = .06) during the subsequent mean follow-up of 3.1 years (range, 1-5.7 years).

CONCLUSIONS

Overall, there was no significant difference in AFS or OS between the two strategies. However, for those patients who survived for at least 2 years after randomization, a BSX-first revascularization strategy was associated with a significant increase in subsequent OS and a trend towards improved AFS.

Changes in health-related quality of life after ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins

BACKGROUND

Health-related quality of life (HRQOL) improves after superficial venous surgery for varicose veins, but the effect of ultrasound-guided foam sclerotherapy on HRQOL is unknown. The aim of this study was to determine changes in HRQOL after ultrasound-guided foam sclerotherapy for varicose veins.

METHODS

Consecutive patients undergoing ultrasound-guided foam sclerotherapy for varicose veins were sent the Short Form 12 (SF-12) questionnaire, a generic measure of HRQOL, and the Aberdeen Varicose Vein Symptom Score (AVSS) questionnaire, a disease-specific measure of HRQOL, 1 week before treatment and 1, 6, and 12 months after treatment.

RESULTS

The study enrolled 296 patients (34% male; 395 treated legs) with a median age of 57 years (range, 22-89 years). Of these, 24% had had previous superficial venous surgery, and 66% were CEAP C(2-3) (uncomplicated varicose veins). Questionnaire completion rates were 82%, 73%, and 69% at 1, 6, and 12 months after treatment. The median Physical Component Summary score of the SF-12 (higher score indicates better HRQOL) improved from 47.6 pretreatment to 49.4 at 1 month (P < .008, Wilcoxon signed rank test), to 51.9 at 6 months (P < .0005), and to 52.9 at 12 months (P < .0005). The median AVSS (lower score indicates better HRQOL) improved from 19.0 pretreatment to 16.5 at 1 month (P < .0005), to 8.7 at 6 months (P < .0005), and to 8.6 at 12 months (P < .0005).

CONCLUSIONS

Ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins leads to significant improvements in generic and disease-specific HRQOL for at least 12 months after treatment.

Medium-term results of ultrasound-guided foam sclerotherapy for small saphenous varicose veins

Background

The results of surgery for small saphenous varicose vein (SSV) varicosities may be suboptimal in terms of recurrence and complications. The role of minimally invasive alternatives remains incompletely defined. The aim was to review the medium-term outcomes of ultrasound-guided foam sclerotherapy (UGFS) for SSV.

Methods

Eighty-six patients (92 legs) undergoing UGFS for SSV were assessed before, and 1, 6 and 12 months after treatment. Outcome measures were occlusion of, and abolition of reflux in, the SSV (technical success), absence of visible varicose veins (clinical success) and improvement in disease-specific health-related quality of life (HRQL) following treatment (Aberdeen Varicose Vein Symptom Severity Score (AVSS)).

Results

The technical and clinical success rates at 12 months were 91 and 93 per cent respectively; only three patients required a second treatment. After treatment of isolated SSV varicosities there was a significant improvement in AVSS, from a median of 19·0 (interquartile range 13·4–26·8) before treatment to 10·2 (4·0–18·3) and 9·7 (3·5–19·1) at 6 and 12 months respectively. The only complication was a popliteal vein thrombosis that required anticoagulation.

Conclusion

UGFS was an effective treatment for SSV, with abolition of reflux and visible varicose veins, and improvement in HRQL for at least 12 months.

Recovery after ultrasound-guided foam sclerotherapy compared with conventional surgery for varicose veins

Background

The advantages of minimally invasive alternatives such as ultrasound-guided foam sclerotherapy (UGFS) over conventional surgery for the treatment of varicose veins include lower morbidity and faster recovery times. The aim was to compare morbidity, analgesia use, and time to return to driving and work following UGFS with those reported after conventional surgery for varicose veins.

Methods

Patients who had UGFS or surgery for varicose veins were sent a questionnaire 4 weeks after treatment.

Results

A total of 332 (84·9 per cent) of 391 patients who had UGFS and 53 (56 per cent) of 94 who had surgery returned a questionnaire. The groups were similar in terms of age, sex, and the proportion who had treatment of bilateral or recurrent veins. Patients who had surgery were more likely to have significant bruising (44 versus 7·2 per cent; P &lt; 0·001) and pain (17 versus 5·5 per cent; P = 0·001). After UGFS, 43·2 per cent of patients returned to work within 24 h compared with none who had surgery (P &lt; 0·001). Patients who had UGFS were more likely to return to driving within 4 days (P = 0·014).

Conclusion

UGFS was associated with less pain and analgesia requirement, time off work and quicker return to driving.

Surgical Versus Endovascular Reconstruction for Chronic Mesenteric Ischemia: A Contemporary UK Series

Objective: To assess the outcome of surgical (SR) and endovascular (ER) reconstruction for chronic mesenteric ischemia (CMI). Methods: Retrospective review of consecutive patients who underwent SR or ER for CMI in 3 UK vascular surgery units between 1996 and 2006. Early (<30 days; technical success, morbidity, mortality, length of hospital stay) and late (>30 days) outcomes (symptom recurrence, vessel/graft patency, reintervention, mortality) were assessed. Results: A total of 27 patients underwent 32 reconstructions (SR = 17, ER = 15). A total of 44 of 56 (79%) diseased arteries underwent SR (n = 26; bypass = 24, reimplantation = 2; occlusion = 16, stenosis = 10) or ER (n = 18; stenosis = 16, occlusion = 2). Perioperative mortality for SR and ER was 6% and 0%, respectively (P ≥ .99). Hospital stay was shorter following ER (mean, 4.3 vs. 14.2 days, P = .0003). Mean (range) follow-up for SR and ER was 34 (1-94) and 34 (0-135) months, respectively. At 2 years, SR demonstrated superior secondary patency (100% vs. 65%) and clinical patency (100% vs. 73%). Conclusions: Surgical mesenteric reconstruction is associated with significantly longer hospital stay, but superior long-term outcome compared to endovascular reconstruction.

A reproducibility study of a TDI-based method to calculate indices of arterial stiffness

The aim of the study was to investigate the reproducibility of estimation of Young's modulus E and pressure strain elastic modulus Ep, derived from a tissue Doppler imaging (TDI) wall motion technique. Healthy subjects had their arteries insonated at the same sitting by two different observers and at two different sittings by the same observer. From 32 subjects in the reproducibility study, within-scan coefficient of variation (CV) was 4.5%. Intraobserver between-scan CV for E was 12.7% and for Ep 11.0%. Interobserver CVs were 8.3% and 9.3%, respectively. TDI is a reproducible, valid and highly sensitive direct assessment of arterial wall parameters. It is at least as reproducible as other ultrasound based methods for assessing arterial stiffness and also provides increased information about the arterial distension waveform.

Effect of ramipril on renal function in patients with intermittent claudication

BACKGROUND

The Heart Outcomes Prevention Study (HOPE) demonstrated that ramipril resulted in a blood-pressure-independent 25% reduction in cardiovascular events in patients with peripheral arterial disease (PAD). Despite this, general practitioners and vascular surgeons remain reluctant to prescribe ACE inhibitors in this group of patients because of concerns about renal artery stenosis (RAS). We aimed to define the effect of ramipril on renal function in patients with intermittent claudication (IC).

METHODS AND RESULTS

Of 132 unselected patients with IC entering the study 78 (59%) were excluded due to: current ACE inhibitor use (38%), renal impairment (serum creatinine above normal range) (15%), known severe RAS (1%) or unwillingness to participate (5%). The remaining 54 patients were titrated to 10 mg ramipril and renal function was monitored at 1, 5, and 12 weeks. Treatment was discontinued during titration in 5 patients due to symptoms (3) or lack of compliance (2). In the remainder, median [IQR] serum creatinine increased (94 [85.8-103.3] to 98 [88.0-106.5] micromol/L, p < or = 0.001) and median [IQR] GFR decreased (71.5 [64.6-82.3] to 68.7 [59.8-74.7] mL/min per 1.73 m2, p < or = 0.001) between baseline and 5 weeks. These changes were not considered clinically significant. By 12 weeks these values had returned almost to baseline (Cr 95.5 [88.0-103.25] micromol/L, GFR 71.8 [65.3-77.4] mL/min). No patient had a serum creatinine rise > 30%.

CONCLUSION

Most of patients with IC and a normal serum creatinine can be safely commenced on ramipril provided they are screened, titrated and monitored as described above. Studies in patients with borderline renal impairment (serum creatinine up to 30% above baseline) are on-going.

Long-term Results of Surgical Repair of Popliteal Artery Aneurysm

OBJECTIVE

To determine the long-term outcome of surgical repair of popliteal artery aneurysms (PAA).

METHODS

A retrospective review of consecutive patients who underwent surgical PAA repair in two vascular surgery units between 1988 and 2006 was performed. Primary and secondary graft patency, limb salvage and patient survival rates were determined using Kaplan-Meier methods.

RESULTS

48 patients underwent repair of 63 PAAs (ligation and bypass=45, interposition grafting=18). The 5-year primary graft patency, secondary graft patency, limb salvage and patient survival rates were 75%, 95%, 98% and 81%, respectively. The 10-year primary graft patency rates were significantly lower for emergency cases (59%) compared with elective cases (66%) (p=0.0023). Thirteen patients (16 PAAs) required a total of 20 late re-interventions. Duplex ultrasound was available in 33 of 45 PAAs treated by ligation and bypass. Five (15%) PAAs demonstrated perfusion of the aneurysm sac at median (range) follow up of 75 (1-246) months after primary repair and two of these required emergency re-operation.

CONCLUSIONS

These data demonstrate that surgical PAA repair is associated with excellent long-term durability and provide an important benchmark with which to compare results of endovascular PAA repair. Patients treated using the ligation and bypass technique should be enrolled in an aneurysm sac surveillance program.

The role of tissue factor in patients undergoing open repair of ruptured and nonruptured abdominal aortic aneurysms

BACKGROUND

Ruptured abdominal aortic aneurysm (AAA) is associated with the development of a procoagulant and hypofibrinolytic state. Tissue factor (TF) and its naturally occurring inhibitor, tissue factor pathway inhibitor (TFPI), play a central role in the initiation and progression of such a hypercoagulable state, but their role in patients undergoing open AAA repair has not previously been examined.

METHODS

A prospective study was conducted of 17 patients undergoing elective AAA repair and 10 patients undergoing emergency AAA repair. Blood was taken before induction, and 5 minutes, 24 hours, and 48 hours after aortic cross-clamp release and assayed for plasma TF, TFPI, tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI), and thrombin-activatable fibrinolysis inhibitor (TAFI) activities.

RESULTS

TF activity was significantly higher at all time points in patients with ruptured AAA compared with nonruptured AAA. The median (interquartile range, IRQ) TF activity (AU/mL) was 9.9 vs 3.2 (IRQ, 5.9 to 12.6 vs 2.0 to 7.6; P = .005) at preinduction; 10.7 vs 1.5 (IRQ, 9.2 to 18.3 vs 0.1 to 6.6; P = .003) at 5 minutes after clamp release; 9.5 vs 3.3 (IRQ, 7.0 to 13.5 vs 1.0 to 7.9; P = .013) at 24 hours, and 9.6 vs 3.9 (IRQ, 7.6 to 12.6 vs 2.4 to 8.7; P = .006) at 48 hours. TFPI levels were not significantly different between ruptured AAA and nonruptured AAA before or during operation but became significantly elevated at 24 and 48 hours in patients who had undergone repair of ruptured AAA. Ruptured AAA repair was associated with a hypofibrinolytic state compared with nonruptured AAA.

CONCLUSIONS

The present study has demonstrated for the first time, to our knowledge, that ruptured AAA is associated with significantly higher perioperative levels of circulating TF compared with nonruptured AAA. Furthermore, in the immediate perioperative period, the high levels of TF are not associated with a corresponding rise in TFPI levels, indicating an unopposed prothrombotic state. Direct inhibition of TF by administration of anti-TF antibodies or recombinant TFPI remains to be evaluated in subjects presenting with hemorrhage due to ruptured AAA, but if given early enough, it may attenuate the early deleterious effects of unopposed TF expression and ultimately contribute to improved outcomes.

Endovascular repair of spontaneous infrarenal aortic dissection presenting as severe lower extremity ischaemia

We report a 90-year old man who presented with severe lower extremity ischaemia due to spontaneous dissection of a non-aneurysmal infrarenal abdominal aorta. The aortic lesion was treated using an aorto-uni-iliac stent-graft with contralateral common iliac artery occlusion and femoro-femoral cross-over bypass. The patient underwent digital amputation and debridement of the foot four weeks post-operatively. At 12 months follow-up, he remains symptom-free with an excluded dissection, patent reconstruction and healed foot.