Relationship between Venous and Arterial Haemodynamics during Postural Changes in Venous Insufficiency

Objective:

To study the changes in central haemodynamics and the relationship between arterial blood pressure and the venous dynamics of the lower limbs in patients with venous insufficiency.

Design:

Prospective haemodynamic study during postural changes in 14 patients with venous insufficiency with no other concomitant cardiovascular disease or disturbances in autonomic nervous system.

Setting:

Department of Cardiology and Angiology, University Hospital, Gent, Belgium.

Patients:

Fourteen patients with venous valve insufficiency in the lower limbs.

Interventions:

Measurements of arterial blood pressure, heart rate, stroke volume and cardiac output were performed in the supine position after 30 min rest and 5, 15 and 30 min after standing and during the recovery. Venous pressure at the ankle and calf circumference were also measured.

Main outcome measures:

Changes in cardiac output and total peripheral vascular resistance in order to maintain blood pressure during postural changes.

Results:

Arterial blood pressure was maintained constant owing to an increase in total peripheral vascular resistance despite a decrease in cardiac output. Venous pressure is also related to arterial blood pressure.

Conclusions:

The arterial and venous systems, even in venous insufficiency, are integrated to maintain blood pressure constant during postural changes.

Meso-Rex shunt using deep femoral vein conduit: first report

The Meso-Rex shunt (MRS) procedure was first described in 1992 by de VILLE et al. for the treatment of extrahepatic portal vein obstruction (EHPVO) in paediatric liver transplant patients. This technique provides more physiological relief of portal hypertension compared to the porto-systemic shunts, which can lead to long-term complications such as hyperammonaemia and hepato-pulmonary syndrome. Different conduits as autologous and cryopreserved veins or prosthetic grafts have been previously reported. We present herein the first case of a MRS using the autologous deep femoral vein in a 17-year-old female patient affected by EHPVO from unknown reasons.

Inhibiting connexin channels protects against cryopreservation-induced cell death in human blood vessels

OBJECTIVES

Cryopreserved blood vessels are being increasingly employed in vascular reconstruction procedures but freezing/thawing is associated with significant cell death that may lead to graft failure. Vascular cells express connexin proteins that form gap junction channels and hemichannels. Gap junction channels directly connect the cytoplasm of adjacent cells and may facilitate the passage of cell death messengers leading to bystander cell death. Two hemichannels form a gap junction channel but these channels are also present as free non-connected hemichannels. Hemichannels are normally closed but may open under stressful conditions and thereby promote cell death. We here investigated whether blocking gap junctions and hemichannels could prevent cell death after cryopreservation.

MATERIALS AND METHODS

Inclusion of Gap27, a connexin channel inhibitory peptide, during cryopreservation and thawing of human saphenous veins and femoral arteries was evaluated by terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assays and histological examination.

RESULTS

We report that Gap27 significantly reduces cell death in human femoral arteries and saphenous veins when present during cryopreservation/thawing. In particular, smooth muscle cell death was reduced by 73% in arteries and 71% in veins, while endothelial cell death was reduced by 32% in arteries and 51% in veins.

CONCLUSIONS

We conclude that inhibiting connexin channels during cryopreservation strongly promotes vascular cell viability.

BRAVISSIMO: 12-month results from a large scale prospective trial

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Treatment of symptomatic mobile aortic thrombus

BACKGROUND

Mobile thoracic or abdominal aortic thrombi are a potential source of embolism to visceral organs or lower limbs. Detection levels of this type of aortic pathology after any embolic event have increased considerably. Nevertheless, therapeutic management of an intraluminal mobile thrombus of the aorta remains controversial. The aim of this study is to describe the treatment modalities for symptomatic mural aortic thrombi based on three cases diagnosed at our institution and to review the literature.

METHODS

During the last decade, several patients with peripheral embolisation were diagnosed with an intraluminal mobile aortic thrombus. Three patients who were treated differently were selected and reviewed. In addition a literature search was performed on PubMed and Medline from their inception to the present for all English language articles using the following keywords: blue toe syndrome, peripheral arterial embolisation, mobile thrombus and aorta. The advantages and drawbacks of medical management, open and endovascular treatment are described.

RESULTS

Three particular patients with embolisation due to a floating aortic thrombus were reviewed. The first patient underwent a thoracotomy with replacement of the descending thoracic aorta. Another case was treated successfully by implanting an endovascular stent graft in the descending thoracic aorta. The last patient was treated medically because of the involvement of the visceral vessels. When reviewing the literature, no randomised controlled trials were found but several case reports have described both open and endovascular techniques. No long-term follow up of this rare pathology is available.

CONCLUSIONS

In the literature there is no consensus how to treat a symptomatic floating aortic thrombus. This report shows that therapeutic strategies are influenced by the localisation of the thrombus, the co-morbidities of the patient and the physician' s preferences. Endovascular treatment in combination with high dose statins has become the preferred treatment method although long-term data are lacking.

[Treatment of iatrogenic femoral pseudoaneurysms by ultrasound-guided percutaneous thrombin injection: effectiveness and complications]

AIM

We retrospectively assessed the effectiveness of ultrasound-guided percutaneous thrombin injection in the treatment of iatrogenic femoral pseudoaneurysms and registered the occurrence of complications in the systemic circulation.

METHODS

We performed ultrasound-guided thrombin injection in 26 iatrogenic femoral pseudoaneurysms: 24 were classified as single en 2 as complex. We registered the volume and the pseudoaneurysm neck measurements, as well as the complication rate.

RESULTS

Ultrasound-guided percutaneous thrombin injection led to a successful obliteration of pseudoaneurysm in 25 out of 26 cases (96.2%). The thrombin amount varied between 250 and 1000 IU. A thrombosis of the common femoral artery after the thrombin injection occurred only in one patient.

CONCLUSION

Ultrasound-guided percutaneous thrombin injection is effective and safe in the treatment of iatrogenic femoral pseudoaneurysms provided the exclusion criteria are respected. Complications are rare.

Endovascular repair of aortic rupture

OBJECTIVES

To report a single centre experience with endovascular repair of ruptures of the descending thoracic and abdominal aorta.

DESIGN

Retrospective non-randomised study in a university hospital.

MATERIAL AND METHODS

Between February 1997 and October 2002, endovascular repair of the aorta was performed on 125 occasions. In 20 cases, this was done as an emergency (nine ruptured infrarenal aortic aneurysms and 11 descending thoracic aortic ruptures). All patients underwent spiral computed tomographic angiography to assess the feasibility of endovascular repair and the size of the endoprosthesis.

RESULTS

Endovascular repair was successfully completed in all patients. Primary conversion to open repair was not necessary. Postoperative 30-day mortality was 5/20 (25%). There were major complications in 12/20 patients. No ruptures of the aneurysms occurred postoperatively. No primary endoleaks occurred, but in 4/20 (20%) secondary surgical interventions were required after a median follow-up of 12 months (range 1-42 months).

CONCLUSION

Our early experience shows the feasibility of this technique with early results that compare favourably to those of emergency open repair. Further studies are required to assess the long-term efficacy.

How to perform a below-knee amputation

Even though modern techniques have improved patient survival and limb salvage rates in patients with critical limb ischaemia and end-stage vascular disease, amputation is sometimes the only possible treatment. In younger patients with traumatic avulsion of a foot, infected gangrene of the foot or a peripheral tumour, amputation is out of discussion and commonly accepted. In older vascular patients, amputation should rather be considered as the starting point for revalidation and rehabilitation than as failure of a revascularization technique. The evolution in prostheses permits a rapid revalidation in most patients. However, an accurate amputation technique is still required to produce a good quality stump allowing early fitting of prosthetics.

Cost-benefit analysis of endovascular versus open abdominal aortic aneurysm treatment

OBJECTIVE

To compare the costs and benefits of open versus endovascular repair of abdominal aortic aneurysm (AAA).

METHODS

A consecutive series of 29 elective patients (open treatment, N = 20 and endovascular treatment, N = 9) were compared retrospectively.

RESULTS

Operating time was significantly shorter for endovascular treatment (mean 90 vs. 125 min, p = 0.026). No endovascular procedure was converted to open surgery; one early endoleak was seen which sealed spontaneously. Endovascular treatment resulted in a shorter ICU and hospital stay (0 days vs. 2 days, p. 0.001 and 5 days vs. 11 days, p = 0.01 respectively). Mean total cost did not differ 361,938 BEF (9,048 Euro) vs. 382,995 BEF (9,575 Euro), p = 0.46. Endovascular treatment generated significantly less hospitalization costs (73,162 BEF or 1,829 Euro vs. 18,2740 BEF or 4,568 Euro, p = 0.001) but required a more expensive implant (153,293 BEF or 3,832 Euro vs. 38,296 BEF or 957 Euro, p = 0.001). Mean total cost for the patient was significantly higher in the endovascular treatment group (66,309 BEF or 1,658 Euro vs. 24,969 BEF or 624 Euro, p = 0.003).

CONCLUSION

Our experience confirms the feasibility and safety of endovascular AAA treatment. It is associated with a shorter ICU and hospital stay and less morbidity. Overall cost for society does not differ significantly as the benefit, of lower hospitalization costs is undone by the high cost of the endovascular graft.

[A case of open bite]

The Authors describe the classification of the malocclusion by Angle, and considerate one open byte case, may be caused by extrusion of first lower right molar, describing orthodontic treatment for his correction.